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General NPI Number Information
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NPI Number | 1871227843
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Entity Type | Individual
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Provider Name | SHAUN DANIEL GAVIN LADC 1
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Gender | Male
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Dates
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Enumeration Date | 07/14/2022
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Last Update Date | 07/14/2022
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Provider Practice Location Address
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Address Line | 300 CONGRESS ST STE 104
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City | QUINCY
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State | MA
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Zip | 02169-0907
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Country | US
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Telephone | 617-774-0331
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Fax | 617-774-0336
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Provider Business Mailing Address
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Address Line | 23 PIERCE ST
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City | HYDE PARK
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State | MA
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Zip | 02136-2981
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Country | US
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Telephone | 857-615-9232
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 12400
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License Number State | MA
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