Provider Demographics
NPI:1730344615
Name:SHAW-WILSON, CINDY ANN (LCADC)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:ANN
Last Name:SHAW-WILSON
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 GREENWICH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-2314
Mailing Address - Country:US
Mailing Address - Phone:410-433-5255
Mailing Address - Fax:410-234-0844
Practice Address - Street 1:5124 GREENWICH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-2314
Practice Address - Country:US
Practice Address - Phone:410-433-5255
Practice Address - Fax:410-234-0844
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD19524389624Medicaid
MD212150600Medicaid