Basic Information
| Provider Information | |||||||||
| NPI: | 1013677723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOVE | ||||||||
| FirstName: | SHADOW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6000 LAMAR AVE STE 130 | ||||||||
| Address2: | |||||||||
| City: | MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662023299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138264200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 W SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660613123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138264200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2021 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 03050-T | KS | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.