=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700623931
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATASHA MARIE GREEN MCCULLOUCH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2024
-----------------------------------------------------
Last Update Date | 07/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 W ORANGETHORPE AVE STE 116
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-4237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-353-2970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 W ORANGETHORPE AVE STE 116
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-4237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-353-2970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------