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General NPI Number Information
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NPI Number | 1821801135
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Entity Type | Individual
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Provider Name | SHANNON THEBADO
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Gender | Female
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Dates
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Enumeration Date | 01/30/2025
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 231 MAIN ST FL 3
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City | BROCKTON
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State | MA
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Zip | 02301-4342
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Country | US
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Telephone | 508-586-2660
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Fax |
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Provider Business Mailing Address
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Address Line | 315 CANTON ST
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City | STOUGHTON
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State | MA
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Zip | 02072-2205
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Country | US
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Telephone | 617-702-6947
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | RN2330456
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License Number State | MA
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