Healthcare Provider Details

I. General information

NPI: 1376321802
Provider Name (Legal Business Name): SHANIKA MCCALLUM-COPPAGE LCPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANIKA COPPAGE

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 10/12/2025
Certification Date: 10/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 MILLENNIUM DR STE 300
BELCAMP MD
21017-1527
US

IV. Provider business mailing address

PO BOX 767
NORTH EAST MD
21901-0767
US

V. Phone/Fax

Practice location:
  • Phone: 443-722-0249
  • Fax: 410-275-3551
Mailing address:
  • Phone: 443-722-0249
  • Fax: 410-275-3551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC16719
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC-0011930
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: