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General NPI Number Information
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NPI Number | 1437965621
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Entity Type | Individual
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Provider Name | SHANE MICHAEL NIELS CADC-1
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Gender | Male
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 5723 MELROSE AVE
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City | LOS ANGELES
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State | CA
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Zip | 90038-3890
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Country | US
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Telephone | 312-810-0685
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Fax | 714-242-7434
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Provider Business Mailing Address
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Address Line | 801 S BERENDO ST APT 214
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City | LOS ANGELES
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State | CA
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Zip | 90005-4277
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Country | US
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Telephone | 312-810-0685
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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