Provider Demographics
NPI:1639529407
Name:CREATE YOUR LIFE, LLC
Entity Type:Organization
Organization Name:CREATE YOUR LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LIC.CLIN. PROF. COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LPC
Authorized Official - Phone:202-422-7337
Mailing Address - Street 1:5008 VANE CT
Mailing Address - Street 2:SUITE 2041
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1526
Mailing Address - Country:US
Mailing Address - Phone:202-422-7337
Mailing Address - Fax:
Practice Address - Street 1:5008 VANE CT
Practice Address - Street 2:SUITE 2041
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1526
Practice Address - Country:US
Practice Address - Phone:202-422-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1508101YP2500X
DCPRC13741101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2132324OtherMAMSI
MD001437100Medicaid
MD743688000OtherMAGELLEAN
DC60980001OtherBLUE CROSS BLUE SHIELD
MD358105OtherMHN
MD645523-03OtherBLUE CROSS BLUE SHIELD