Provider Demographics
NPI:1205534377
Name:CORDOBA, SHALAIYAH (LGMFT)
Entity type:Individual
Prefix:
First Name:SHALAIYAH
Middle Name:
Last Name:CORDOBA
Suffix:
Gender:F
Credentials:LGMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8158 WASHINGTON BLVD APT 433
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:MD
Mailing Address - Zip Code:20794-8801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 W TIMONIUM RD STE 207
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-3105
Practice Address - Country:US
Practice Address - Phone:443-729-0828
Practice Address - Fax:443-819-1321
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGM934106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist