Basic Information
| Provider Information | |||||||||
| NPI: | 1437751724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 LAURIE LN | ||||||||
| Address2: | |||||||||
| City: | CHARLTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015071264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7742531128 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1881 WORCESTER RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017015410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086286300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2020 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.