Healthcare Provider Details

I. General information

NPI: 1942606595
Provider Name (Legal Business Name): SHANNON KAMMHOLZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 06/08/2025
Certification Date: 06/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12304 SANTA MONICA BLVD STE 364
LOS ANGELES CA
90025-1542
US

IV. Provider business mailing address

817 10TH ST UNIT 102
SANTA MONICA CA
90403-1619
US

V. Phone/Fax

Practice location:
  • Phone: 303-710-5631
  • Fax:
Mailing address:
  • Phone: 303-710-5631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number26569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: