Healthcare Provider Details

I. General information

NPI: 1952659328
Provider Name (Legal Business Name): SHANNON ISAACS MARBLE LCPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 04/19/2020
Certification Date: 04/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N MAIN ST
UNION BRIDGE MD
21791-9102
US

IV. Provider business mailing address

106 N MAIN ST
UNION BRIDGE MD
21791-9102
US

V. Phone/Fax

Practice location:
  • Phone: 443-340-1603
  • Fax:
Mailing address:
  • Phone: 443-340-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC5584
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: