Healthcare Provider Details

I. General information

NPI: 1912439001
Provider Name (Legal Business Name): SHANNON MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

IV. Provider business mailing address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

V. Phone/Fax

Practice location:
  • Phone: 410-780-5203
  • Fax: 410-780-5205
Mailing address:
  • Phone: 410-780-5203
  • Fax: 410-780-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16339
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: