Provider Demographics
NPI:1477809119
Name:MOORE REYNOLDS, SHAUNA (EDD, NCC,LPC, LCPC)
Entity Type:Individual
Prefix:DR
First Name:SHAUNA
Middle Name:
Last Name:MOORE REYNOLDS
Suffix:
Gender:F
Credentials:EDD, NCC,LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-0275
Mailing Address - Country:US
Mailing Address - Phone:240-389-1487
Mailing Address - Fax:240-389-1463
Practice Address - Street 1:11785 BELTSVILLE DR STE 120
Practice Address - Street 2:
Practice Address - City:CALVERTON
Practice Address - State:MD
Practice Address - Zip Code:20705-3121
Practice Address - Country:US
Practice Address - Phone:240-389-1487
Practice Address - Fax:240-389-1463
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPCR14291101YM0800X, 101Y00000X, 106H00000X
DCPRC14291101YP2500X
MDLC4866101Y00000X, 101YM0800X, 106H00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0647632P0000Medicaid