Provider Demographics
NPI:1730917931
Name:PARRISH-BACON, SHANIQUA
Entity type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:
Last Name:PARRISH-BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8284 VOSGES RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-3367
Mailing Address - Country:US
Mailing Address - Phone:410-913-3911
Mailing Address - Fax:
Practice Address - Street 1:8284 VOSGES RD
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-3367
Practice Address - Country:US
Practice Address - Phone:410-913-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC13086101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health