Provider Demographics
NPI:1871920140
Name:MADONNA HALL GOOD SHEPHERD SERVICES
Entity type:Organization
Organization Name:MADONNA HALL GOOD SHEPHERD SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:671-471-5686
Mailing Address - Street 1:1354 HANCOCK ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5109
Mailing Address - Country:US
Mailing Address - Phone:617-471-5686
Mailing Address - Fax:617-471-6622
Practice Address - Street 1:1354 HANCOCK ST
Practice Address - Street 2:SUITE 209
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5109
Practice Address - Country:US
Practice Address - Phone:617-471-5686
Practice Address - Fax:617-471-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1379106H00000X
MA144225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty