=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467296053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LASHAUNE SHERICE RECKE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2024
-----------------------------------------------------
Last Update Date | 06/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 N BRAND BLVD STE 100
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91203-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 747-286-2600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4400 W RIVERSIDE DR # 110-329
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-415-0774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101200000X
-----------------------------------------------------
Taxonomy Name | Drama Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------