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General NPI Number Information
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NPI Number | 1275631723
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Entity Type | Individual
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Provider Name | SHANNON CHRISTINE SECRIST LICSW
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Gender | Female
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/05/2024
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Provider Practice Location Address
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Address Line | 529 MAIN ST STE 100
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City | CHARLESTOWN
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State | MA
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Zip | 02129-1119
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Country | US
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Telephone | 617-756-2151
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Fax |
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Provider Business Mailing Address
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Address Line | 406 TECHNOLOGY CENTER DR UNIT 4409
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City | STOUGHTON
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State | MA
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Zip | 02072-4738
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Country | US
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Telephone | 530-520-9319
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LICSW126386
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS23562
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License Number State | CA
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