1619046919 NPI number — REGINALD HARRISON SHOCKLEY SR. LCSW-C

Table of content: REGINALD HARRISON SHOCKLEY SR. LCSW-C (NPI 1619046919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619046919 NPI number — REGINALD HARRISON SHOCKLEY SR. LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOCKLEY
Provider First Name:
REGINALD
Provider Middle Name:
HARRISON
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
LCSW-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619046919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34462 FOX HOUND CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARSONSBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21849-2676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-614-5360
Provider Business Mailing Address Fax Number:
410-334-6960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 MILFORD ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-334-6961
Provider Business Practice Location Address Fax Number:
410-334-6960
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 24065 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 517251 . This is a "UHC MAMSI GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: LM49EA . This is a "CAREFIRST BCBS GROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: R968 . This is a "CAREFIRST FEDERAL GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 609550001 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 259147000 . This is a "MAGELLAN GROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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