Healthcare Provider Details

I. General information

NPI: 1184171324
Provider Name (Legal Business Name): SHANNON MARIE REILLEY LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SOLAREX CT UNIT 201
FREDERICK MD
21703-8655
US

IV. Provider business mailing address

35 E CHURCH ST UNIT A
MOUNT AIRY MD
21771-5463
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-8263
  • Fax:
Mailing address:
  • Phone: 240-527-9395
  • Fax: 410-334-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number22951
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: