Provider Demographics
NPI:1700363173
Name:SHEA, MARY ELLEN (LC7836)
Entity Type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:LC7836
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7309 BEECHTREE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21769-7604
Mailing Address - Country:US
Mailing Address - Phone:240-357-5410
Mailing Address - Fax:
Practice Address - Street 1:23 E PATRICK ST STE 300
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6162
Practice Address - Country:US
Practice Address - Phone:240-357-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7836101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty