Provider Demographics
NPI:1184171324
Name:REILLEY, SHANNON MARIE (LCSW-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:REILLEY
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E CHURCH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5463
Mailing Address - Country:US
Mailing Address - Phone:240-527-9395
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:604 SOLAREX CT UNIT 201
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8655
Practice Address - Country:US
Practice Address - Phone:301-663-8263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MD22951104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609550001Medicaid