Healthcare Provider Details

I. General information

NPI: 1598721441
Provider Name (Legal Business Name): SHAUN PATRICK LABLANCE PHD FLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N BLDG 1300
NELLIS AFB NV
89191-6600
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD. BLDG 1300
NELLIS AFB NV
89191-6601
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-2965
  • Fax: 702-653-3622
Mailing address:
  • Phone: 702-653-2965
  • Fax: 702-653-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301007989
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: