Provider Demographics
NPI:1255155198
Name:SHIFFLETT, NICOLE A (LGPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:SHIFFLETT
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2938 HAMPSTEAD MEXICO RD
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-1513
Mailing Address - Country:US
Mailing Address - Phone:443-974-5495
Mailing Address - Fax:
Practice Address - Street 1:1812 BALTIMORE BLVD STE A
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-7144
Practice Address - Country:US
Practice Address - Phone:410-871-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSHIF-109Q32101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health