Healthcare Provider Details

I. General information

NPI: 1316412570
Provider Name (Legal Business Name): SHANNON LYNN LATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 02/13/2021
Certification Date: 02/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23133 VENTURA BLVD STE 103
WOODLAND HILLS CA
91364-1184
US

IV. Provider business mailing address

6 PEREGRINE CIR
OAK PARK CA
91377-1321
US

V. Phone/Fax

Practice location:
  • Phone: 818-489-1156
  • Fax:
Mailing address:
  • Phone: 818-489-1156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number105866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: