Provider Demographics
NPI:1619046919
Name:SHOCKLEY, REGINALD HARRISON SR (LCSW-C)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:HARRISON
Last Name:SHOCKLEY
Suffix:SR
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34462 FOX HOUND CT
Mailing Address - Street 2:
Mailing Address - City:PARSONSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21849-2676
Mailing Address - Country:US
Mailing Address - Phone:443-614-5360
Mailing Address - Fax:410-334-6960
Practice Address - Street 1:106 MILFORD ST STE 201
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6960
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MD240651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
517251OtherUHC MAMSI GROUP #
MDLM49EAOtherCAREFIRST BCBS GROUP
R968OtherCAREFIRST FEDERAL GROUP
MD609550001Medicaid
MD259147000OtherMAGELLAN GROUP