Healthcare Provider Details

I. General information

NPI: 1891413647
Provider Name (Legal Business Name): DR. SHANE MATTHEW MORALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 MOUNTAIN RD STE D
PASADENA MD
21122-2025
US

IV. Provider business mailing address

100 E REDWOOD ST APT 2014
BALTIMORE MD
21202-1361
US

V. Phone/Fax

Practice location:
  • Phone: 410-255-4833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number29091
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: