Provider Demographics
NPI:1518511237
Name:MCCALLUM, SHAMIA KEONA
Entity Type:Individual
Prefix:
First Name:SHAMIA
Middle Name:KEONA
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6218 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2021
Mailing Address - Country:US
Mailing Address - Phone:410-971-0370
Mailing Address - Fax:410-971-0370
Practice Address - Street 1:1515 MARTIN BLVD STE 206
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-4103
Practice Address - Country:US
Practice Address - Phone:410-971-0370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24991104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD38-3876389Medicaid