Healthcare Provider Details

I. General information

NPI: 1841829223
Provider Name (Legal Business Name): SHANNAN N EADDY ADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30007 BUSINESS CENTER DR
CHARLOTTE HALL MD
20622-3101
US

IV. Provider business mailing address

30007 BUSINESS CENTER DR
CHARLOTTE HALL MD
20622-3101
US

V. Phone/Fax

Practice location:
  • Phone: 301-997-1300
  • Fax: 301-290-0280
Mailing address:
  • Phone: 301-997-1300
  • Fax: 301-290-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2178
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: