Healthcare Provider Details

I. General information

NPI: 1477809119
Provider Name (Legal Business Name): SHAUNA MOORE REYNOLDS ED.D., NCC,LPC, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11785 BELTSVILLE DR STE 120
CALVERTON MD
20705-3121
US

IV. Provider business mailing address

PO BOX 275
BURTONSVILLE MD
20866-0275
US

V. Phone/Fax

Practice location:
  • Phone: 240-389-1487
  • Fax: 240-389-1463
Mailing address:
  • Phone: 240-389-1487
  • Fax: 240-389-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPCR14291
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC14291
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPCR14291
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC4866
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC4866
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLC4866
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberPCR14291
License Number StateDC
# 8
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC4866
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: