Healthcare Provider Details

I. General information

NPI: 1508278979
Provider Name (Legal Business Name): SHANNON EDMISTON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 YORK RD T300
BALTIMORE MD
21212-3610
US

IV. Provider business mailing address

5820 YORK RD T300
BALTIMORE MD
21212-3610
US

V. Phone/Fax

Practice location:
  • Phone: 410-989-3899
  • Fax: 410-777-8742
Mailing address:
  • Phone: 410-989-3899
  • Fax: 410-777-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC5373
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: