Provider Demographics
NPI:1164980074
Name:HACKLEY, SHANICE (LGSW)
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:HACKLEY
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 MORRISON CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21226-1317
Mailing Address - Country:US
Mailing Address - Phone:443-687-1147
Mailing Address - Fax:
Practice Address - Street 1:3800 FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-3618
Practice Address - Country:US
Practice Address - Phone:443-687-1147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-10
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD220311041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool