=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306662697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNEL HELEN KASSIS ELHELOU PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2024
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 20TH ST STE 150
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-582-7641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12791 LONE TRAIL CT
-----------------------------------------------------
City | MOORPARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93021-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-800-0514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 35236
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------