Healthcare Provider Details

I. General information

NPI: 1174668669
Provider Name (Legal Business Name): LEE ANN KENNEY-SHOUP LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MILFORD STREET 104
SALISBURY MD
21804-6953
US

IV. Provider business mailing address

106 MILFORD STREET 104
SALISBURY MD
21804
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-8291
  • Fax: 410-341-6275
Mailing address:
  • Phone: 410-543-8291
  • Fax: 410-341-6275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2137
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: