Provider Demographics
NPI:1316412570
Name:LATSON, SHANNON LYNN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:LATSON
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 1:6 PEREGRINE CIR
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-1321
Mailing Address - Country:US
Mailing Address - Phone:818-489-1156
Mailing Address - Fax:
Practice Address - Street 1:23133 VENTURA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1184
Practice Address - Country:US
Practice Address - Phone:818-489-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105866102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst