Healthcare Provider Details

I. General information

NPI: 1639791114
Provider Name (Legal Business Name): IHEAL WELLNESS THERAPY AND CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6726A INDUSTRIAL DR
BELTSVILLE MD
20705-1237
US

IV. Provider business mailing address

10125 COLESVILLE RD STE 204
SILVER SPRING MD
20901-2457
US

V. Phone/Fax

Practice location:
  • Phone: 410-756-0477
  • Fax:
Mailing address:
  • Phone: 410-756-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. SHANNON R. JORDAN
Title or Position: DIRECTOR
Credential: LCSW-C, LICSW
Phone: 410-756-0477