Provider Information for 1790431096
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SHANNON LATRAY LCPC
Sex: Female
NPI: 1790431096
Last Updated: 2024-10-04
Certification Date: 2024-10-04
Certification Date: 2024-10-04
Details
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| NPI | 1790431096 | ||||||||||||||||||||||||||||||||||||
| Enumeration Date | 2022-02-24 | ||||||||||||||||||||||||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||||||||||||||||||||||||
| Sole Proprietor | NO | ||||||||||||||||||||||||||||||||||||
| Status | Active | ||||||||||||||||||||||||||||||||||||
| Mailing Address | 22 BRIMSTONE ST STE A BUTTE, MT 59701-4978 United States Phone: 406-560-2799 | Fax: | ||||||||||||||||||||||||||||||||||||
| Primary Practice Address | 22 BRIMSTONE ST STE A BUTTE, MT 59701-4978 United States Phone: 406-560-2799 | Fax: | ||||||||||||||||||||||||||||||||||||
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