Provider Demographics
NPI:1538423629
Name:WIECHELT, SHELLY A (PHD, LCSW-C, CCDC)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:A
Last Name:WIECHELT
Suffix:
Gender:F
Credentials:PHD, LCSW-C, CCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CLAY ST
Mailing Address - Street 2:NATIVE AMERICAN LIFELINES
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-3501
Mailing Address - Country:US
Mailing Address - Phone:410-837-2258
Mailing Address - Fax:410-837-2692
Practice Address - Street 1:106 CLAY ST
Practice Address - Street 2:NATIVE AMERICAN LIFELINES
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3501
Practice Address - Country:US
Practice Address - Phone:410-837-2258
Practice Address - Fax:410-837-2692
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD128271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical