Provider Demographics
NPI:1407562200
Name:ANDERSON, SHADIYAH (LMSW)
Entity Type:Individual
Prefix:
First Name:SHADIYAH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3305
Mailing Address - Country:US
Mailing Address - Phone:410-764-8560
Mailing Address - Fax:410-764-9114
Practice Address - Street 1:4201 PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3305
Practice Address - Country:US
Practice Address - Phone:410-764-8560
Practice Address - Fax:410-764-9114
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24764104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker