Provider Demographics
NPI:1508278979
Name:EDMISTON, SHANNON (LCPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 YORK RD
Mailing Address - Street 2:T300
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3610
Mailing Address - Country:US
Mailing Address - Phone:410-989-3899
Mailing Address - Fax:410-777-8742
Practice Address - Street 1:5820 YORK RD
Practice Address - Street 2:T300
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3610
Practice Address - Country:US
Practice Address - Phone:410-989-3899
Practice Address - Fax:410-777-8742
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5373101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty