Provider Demographics
NPI:1457104572
Name:HELLER, SHANNON (LGPC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HELLER
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 1:1110 BENFIELD BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-2645
Mailing Address - Country:US
Mailing Address - Phone:410-987-2031
Mailing Address - Fax:
Practice Address - Street 1:1110 BENFIELD BLVD STE J
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2645
Practice Address - Country:US
Practice Address - Phone:410-987-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC15283101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty