Basic Information
| Provider Information | |||||||||
| NPI: | 1336307800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDERMOTT | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | MULLEN | ||||||||
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| Credential: | PHD, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1750 E FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212311534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439239400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1750 E FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212311534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439239400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103T00000X | 05422 | MD | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.