Provider Demographics
NPI:1467669051
Name:SHANK, THERESA (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:SHANK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W 40TH ST
Mailing Address - Street 2:SUITE 428
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2120
Mailing Address - Country:US
Mailing Address - Phone:410-979-2326
Mailing Address - Fax:410-979-2326
Practice Address - Street 1:711 W 40TH ST
Practice Address - Street 2:SUITE 428
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2120
Practice Address - Country:US
Practice Address - Phone:410-979-2326
Practice Address - Fax:410-979-2326
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3114103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical