=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457118598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATISHA SHUNA BALL LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2024
-----------------------------------------------------
Last Update Date | 03/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 NUTMEG ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-6212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-271-5530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4211 CARTULINA RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92124-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-761-2741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 141329
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------