Provider Demographics
NPI:1073048070
Name:SHANNON, PRECHELLE
Entity Type:Individual
Prefix:
First Name:PRECHELLE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12801 OLD FORT RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-2844
Mailing Address - Country:US
Mailing Address - Phone:240-423-5390
Mailing Address - Fax:240-260-0743
Practice Address - Street 1:12801 OLD FORT RD
Practice Address - Street 2:SUITE 303
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-2844
Practice Address - Country:US
Practice Address - Phone:240-423-5390
Practice Address - Fax:240-260-0743
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14836101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional