Basic Information
| Provider Information | |||||||||
| NPI: | 1619046919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOCKLEY | ||||||||
| FirstName: | REGINALD | ||||||||
| MiddleName: | HARRISON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34462 FOX HOUND CT | ||||||||
| Address2: | |||||||||
| City: | PARSONSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218492676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436145360 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 MILFORD ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 24065 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 517251 | 01 | UHC MAMSI GROUP # | OTHER | LM49EA | 01 | MD | CAREFIRST BCBS GROUP | OTHER | R968 | 01 | CAREFIRST FEDERAL GROUP | OTHER | 609550001 | 05 | MD | MEDICAID | 259147000 | 01 | MD | MAGELLAN GROUP | OTHER |