Provider Demographics
NPI:1548481724
Name:SHACK, MARILE YVONNE (LGPC)
Entity type:Individual
Prefix:MRS
First Name:MARILE
Middle Name:YVONNE
Last Name:SHACK
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 1:6012 WESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2909
Mailing Address - Country:US
Mailing Address - Phone:240-898-0384
Mailing Address - Fax:
Practice Address - Street 1:1620 ELTON RD STE 204
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-1760
Practice Address - Country:US
Practice Address - Phone:301-439-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP098101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLGP098OtherPROFESSIONAL COUNSELOR