Provider Demographics
NPI:1205096526
Name:ROSHELL, SHANTEL S
Entity type:Individual
Prefix:
First Name:SHANTEL
Middle Name:S
Last Name:ROSHELL
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 1:2080 FLORENCE AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043
Mailing Address - Country:US
Mailing Address - Phone:323-632-8337
Mailing Address - Fax:
Practice Address - Street 1:2080 FLORENCE AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043
Practice Address - Country:US
Practice Address - Phone:323-710-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 104100000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner