Provider Demographics
NPI:1538230891
Name:SHAKESPEARE, LESLIE DONOVAN (LICSW MSW)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:DONOVAN
Last Name:SHAKESPEARE
Suffix:
Gender:F
Credentials:LICSW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474
Mailing Address - Country:US
Mailing Address - Phone:617-732-3921
Mailing Address - Fax:781-620-1293
Practice Address - Street 1:390 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474
Practice Address - Country:US
Practice Address - Phone:617-732-3921
Practice Address - Fax:781-620-1293
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1030393104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1853686Medicaid
MAP21491Medicare PIN