Provider Demographics
NPI:1578796850
Name:ZELLNER, LASHELLE
Entity Type:Individual
Prefix:
First Name:LASHELLE
Middle Name:
Last Name:ZELLNER
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 1:6541 SPECKER AVE BLDG 1830
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4263
Mailing Address - Country:US
Mailing Address - Phone:719-503-7847
Mailing Address - Fax:
Practice Address - Street 1:300 EAST HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30909-5650
Practice Address - Country:US
Practice Address - Phone:706-840-5741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-004685103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid