MEDICARE: MS. SHAINNA SADE WILSON LGPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LGPC7456	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841730306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAINNA SADE WILSON LGPC

Provider Business Mailing Address
First Line	:	1618 KINGSWAY RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-1612
Country	:	US
Telephone Number	:	551-404-8492
Fax Number	:

Provider Business Practice Location Address
First Line	:	1618 KINGSWAY RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-1612
Country	:	US
Telephone Number	:	551-404-8492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2017
Last Update Date	:	03/03/2017

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