=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629746110
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLY DE SILVA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2021
-----------------------------------------------------
Last Update Date | 08/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4601 PRESIDENTS DR STE 135
-----------------------------------------------------
City | LANHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20706-4894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-473-3404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4211 RUSSELL AVE APT 2
-----------------------------------------------------
City | MOUNT RAINIER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20712-1724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-391-6664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LGP11845
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------