Basic Information
| Provider Information | |||||||||
| NPI: | 1689722399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAKUN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 103 GLEN ST | ||||||||
| Address2: | |||||||||
| City: | MALDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021481105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814385550 | ||||||||
| FaxNumber: | 7814385553 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 MAIN ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | STONEHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021803580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814385550 | ||||||||
| FaxNumber: | 7814385553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 7113 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 7113 | MA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.