Provider Demographics
NPI:1629746144
Name:TAYLOR, SHASTA DENNINE (LCPC, LCADC, NCC)
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:DENNINE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LCPC, LCADC, NCC
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:DENNINE
Other - Last Name:JARMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, LCADC, NCC
Mailing Address - Street 1:13653 CROWS FOOT LN
Mailing Address - Street 2:
Mailing Address - City:PRINCESS ANNE
Mailing Address - State:MD
Mailing Address - Zip Code:21853-3211
Mailing Address - Country:US
Mailing Address - Phone:140-845-1796
Mailing Address - Fax:
Practice Address - Street 1:13653 CROWS FOOT LN
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-3211
Practice Address - Country:US
Practice Address - Phone:140-845-1796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA2707101YA0400X
MDLC8064101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)