Healthcare Provider Details

I. General information

NPI: 1801584602
Provider Name (Legal Business Name): SHANTEL NICO HAMS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11901 JESSICA LN
RAYTOWN MO
64138-2639
US

IV. Provider business mailing address

11901 JESSICA LN
RAYTOWN MO
64138-2639
US

V. Phone/Fax

Practice location:
  • Phone: 816-203-8513
  • Fax: 816-886-7632
Mailing address:
  • Phone: 816-203-8513
  • Fax: 816-886-7632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2022016958
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: