Provider Demographics
NPI:1043330590
Name:SEIDENBERG, SHANA ENGQUIST (MSW)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:ENGQUIST
Last Name:SEIDENBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 STILLMAN ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02113-1647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 COURT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-2601
Practice Address - Country:US
Practice Address - Phone:617-371-1714
Practice Address - Fax:617-371-1756
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539372-01Medicaid