Provider Demographics
NPI:1871227843
Name:GAVIN, SHAUN DANIEL (LADC 1)
Entity type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:DANIEL
Last Name:GAVIN
Suffix:
Gender:M
Credentials:LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2981
Mailing Address - Country:US
Mailing Address - Phone:857-615-9232
Mailing Address - Fax:
Practice Address - Street 1:300 CONGRESS ST STE 104
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0907
Practice Address - Country:US
Practice Address - Phone:617-774-0331
Practice Address - Fax:617-774-0336
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)