Provider Demographics
NPI:1235587486
Name:LATIMORE, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LATIMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 S NELLIS BLVD APT 2017
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7705
Mailing Address - Country:US
Mailing Address - Phone:612-239-1500
Mailing Address - Fax:
Practice Address - Street 1:3055 S NELLIS BLVD APT 2017
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121
Practice Address - Country:US
Practice Address - Phone:612-239-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 103K00000X
NV171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator