Basic Information
| Provider Information | |||||||||
| NPI: | 1902443708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | SHALONN | ||||||||
| MiddleName: | LATRICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 673 SAN JOSE AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941104914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152823789 | ||||||||
| FaxNumber: | 4156950829 | ||||||||
| Practice Location | |||||||||
| Address1: | 673 SAN JOSE AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941104914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152823789 | ||||||||
| FaxNumber: | 4156950829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2019 | ||||||||
| LastUpdateDate: | 11/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.