Healthcare Provider Details

I. General information

NPI: 1710864228
Provider Name (Legal Business Name): RYAN SHANLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MILLET ST STE 203
RICHMOND VT
05477-9623
US

IV. Provider business mailing address

PO BOX 179
RICHMOND VT
05477-0179
US

V. Phone/Fax

Practice location:
  • Phone: 802-242-1353
  • Fax:
Mailing address:
  • Phone: 802-242-1353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number097.0135739
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: