1922597723 NPI number — SHANTA LATRICE HOBBS MS, LPC-IT, SAC-IT

Table of content: SHANTA LATRICE HOBBS MS, LPC-IT, SAC-IT (NPI 1922597723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922597723 NPI number — SHANTA LATRICE HOBBS MS, LPC-IT, SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOBBS
Provider First Name:
SHANTA
Provider Middle Name:
LATRICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC-IT, SAC-IT
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1922597723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8062 W HERBERT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53218-3629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-477-5575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3090 N 53RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53210-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-254-4703
Provider Business Practice Location Address Fax Number:
414-210-2222
Provider Enumeration Date:
05/07/2018

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: 101YA0400X , with the licence number:  18238-130 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 3894-226 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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