MEDICARE: SHANNON RENEE WILLEY M.ED

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	101YM0800X	Mental Health Counselor	LGP11287	MD

General Provider Information

NPI Number	:	1891076337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON RENEE WILLEY M.ED

Provider Business Mailing Address
First Line	:	21270 MAYFAIRE LN UNIT 301
Second Line	:
City	:	LEXINGTON PARK
State	:	MD
Zip	:	20653-5394
Country	:	US
Telephone Number	:	410-463-1655
Fax Number	:

Provider Business Practice Location Address
First Line	:	21270 MAYFAIRE LN UNIT 301
Second Line	:
City	:	LEXINGTON PARK
State	:	MD
Zip	:	20653-5394
Country	:	US
Telephone Number	:	410-463-1655
Fax Number	:

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

Provider Enumeration Date	:	08/29/2011
Last Update Date	:	04/13/2021

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