Provider Demographics
NPI:1336307800
Name:MCDERMOTT, SHELLEY MULLEN (PHD, BCBA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:MULLEN
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1534
Mailing Address - Country:US
Mailing Address - Phone:443-923-9400
Mailing Address - Fax:
Practice Address - Street 1:1750 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1534
Practice Address - Country:US
Practice Address - Phone:443-923-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MD05422103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst