Provider Demographics
NPI:1104679745
Name:BENNETT, SHANNON GABRIELLE (ADT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GABRIELLE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 NATIONAL HWY SW STE 5&6
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6573
Mailing Address - Country:US
Mailing Address - Phone:866-922-1856
Mailing Address - Fax:
Practice Address - Street 1:14701 NATIONAL HWY SW STE 5&6
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-6573
Practice Address - Country:US
Practice Address - Phone:866-922-1856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3502101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)