Provider Demographics
NPI:1639743123
Name:HAMILTON, SHANNTELL K (LCPC)
Entity Type:Individual
Prefix:MISS
First Name:SHANNTELL
Middle Name:K
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SHANNTELL
Other - Middle Name:
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC NBCC
Mailing Address - Street 1:PO BOX 6554
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-6554
Mailing Address - Country:US
Mailing Address - Phone:917-520-0621
Mailing Address - Fax:
Practice Address - Street 1:3030 GREENMOUNT AVE STE 250
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-6905
Practice Address - Country:US
Practice Address - Phone:443-554-8905
Practice Address - Fax:410-480-0110
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC12278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD206933401Medicaid