Healthcare Provider Details

I. General information

NPI: 1386228427
Provider Name (Legal Business Name): SHANA ALYSSA SLATER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 REDLAND CT STE 102
OWINGS MILLS MD
21117-3265
US

IV. Provider business mailing address

64 PARSON RD APT 2
CLIFTON NJ
07012-1505
US

V. Phone/Fax

Practice location:
  • Phone: 443-884-5570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1235
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: