1932118742 NPI number — SHANNON PURTELL LATTIMORE LPC SUPERVISOR

Table of content: SHANNON PURTELL LATTIMORE LPC SUPERVISOR (NPI 1932118742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932118742 NPI number — SHANNON PURTELL LATTIMORE LPC SUPERVISOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATTIMORE
Provider First Name:
SHANNON
Provider Middle Name:
PURTELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC SUPERVISOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PURTELL
Provider Other First Name:
SHANNON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1932118742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4801 FRANKFORD RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75287-5329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-620-6860
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9304 FOREST LN
Provider Second Line Business Practice Location Address:
#100 SOUTH
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75243-6238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-340-0208
Provider Business Practice Location Address Fax Number:
214-340-7092
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  17152 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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