Provider Demographics
NPI:1366812067
Name:LATTA, SHANELL KEHAULANI (MS)
Entity type:Individual
Prefix:MRS
First Name:SHANELL
Middle Name:KEHAULANI
Last Name:LATTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 VELVA DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6326
Mailing Address - Country:US
Mailing Address - Phone:406-212-8670
Mailing Address - Fax:
Practice Address - Street 1:22 VELVA DR
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6326
Practice Address - Country:US
Practice Address - Phone:406-212-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-TMP-4108235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist