Healthcare Provider Details

I. General information

NPI: 1033868534
Provider Name (Legal Business Name): DANIELLE NADINE SHEALLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14701 NATIONAL HWY SW STE 5&6
LAVALE MD
21502-6573
US

IV. Provider business mailing address

14701 NATIONAL HWY SW STE 5&6
LAVALE MD
21502-6573
US

V. Phone/Fax

Practice location:
  • Phone: 301-687-0940
  • Fax: 301-687-0948
Mailing address:
  • Phone: 301-687-0940
  • Fax: 301-687-0948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC2810
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: