Healthcare Provider Details

I. General information

NPI: 1336651090
Provider Name (Legal Business Name): SHIVON MASSENBURG NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 06/02/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2138 PRIEST BRIDGE CT STE 1
CROFTON MD
21114-2463
US

IV. Provider business mailing address

PO BOX 1425
BOWIE MD
20717-1425
US

V. Phone/Fax

Practice location:
  • Phone: 443-351-8033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: