Provider Demographics
NPI:1447525811
Name:DUPERAULT, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:DUPERAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:367 PINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1930
Practice Address - Country:US
Practice Address - Phone:413-737-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-18
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health