Provider Demographics
NPI:1902902950
Name:BURGESS, SHAUNA (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRONT ST STE 406
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:NH
Mailing Address - Zip Code:03833-2727
Mailing Address - Country:US
Mailing Address - Phone:617-306-0610
Mailing Address - Fax:617-337-4412
Practice Address - Street 1:24 FRONT ST STE 406
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833
Practice Address - Country:US
Practice Address - Phone:617-306-0610
Practice Address - Fax:617-337-4412
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110871101YM0800X
1041C0700X
NH1327101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1902902950Medicare NSC