Provider Demographics
NPI:1780418368
Name:SMITH, SHANNA NICOLE (PSYCHOLOGY ASSOCIATE)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYCHOLOGY ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9314 CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1273
Mailing Address - Country:US
Mailing Address - Phone:678-230-6153
Mailing Address - Fax:
Practice Address - Street 1:7505 GREENWAY CENTER DR FL 2
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3507
Practice Address - Country:US
Practice Address - Phone:833-467-3862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA0996101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health