Healthcare Provider Details

I. General information

NPI: 1164980074
Provider Name (Legal Business Name): SHANICE HACKLEY LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2019
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10910 CLARKSVILLE PIKE
ELLICOTT CITY MD
21042-6106
US

IV. Provider business mailing address

10910 CLARKSVILLE PIKE
ELLICOTT CITY MD
21042-6106
US

V. Phone/Fax

Practice location:
  • Phone: 410-313-6600
  • Fax:
Mailing address:
  • Phone: 410-313-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number22031
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: