Healthcare Provider Details

I. General information

NPI: 1003187220
Provider Name (Legal Business Name): SHANTEL ELESSIE MA, ATR-BC, LCPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 FARRAGUT AVE STE 301
KENSINGTON MD
20895-2110
US

IV. Provider business mailing address

3720 FARRAGUT AVE STE 301
KENSINGTON MD
20895-2110
US

V. Phone/Fax

Practice location:
  • Phone: 240-242-5031
  • Fax:
Mailing address:
  • Phone: 240-242-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: