Provider Demographics
NPI:1891076337
Name:WILLEY, SHANNON RENEE (MED)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:WILLEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21270 MAYFAIRE LN UNIT 301
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-5394
Mailing Address - Country:US
Mailing Address - Phone:410-463-1655
Mailing Address - Fax:
Practice Address - Street 1:21270 MAYFAIRE LN UNIT 301
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-5394
Practice Address - Country:US
Practice Address - Phone:410-463-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11287101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609550002Medicaid
MD609500300Medicaid