Provider Demographics
NPI:1619618543
Name:SHADE, LATAYVIA RENEE (QBA)
Entity Type:Individual
Prefix:
First Name:LATAYVIA
Middle Name:RENEE
Last Name:SHADE
Suffix:
Gender:F
Credentials:QBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4288 CARTEGENA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-6504
Mailing Address - Country:US
Mailing Address - Phone:615-347-3115
Mailing Address - Fax:
Practice Address - Street 1:4288 CARTEGENA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-6504
Practice Address - Country:US
Practice Address - Phone:615-347-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health