Basic Information
| Provider Information | |||||||||
| NPI: | 1831631639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OGDEN | ||||||||
| FirstName: | SHANTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 SAN JACINTO RIVER RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925304400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516749243 | ||||||||
| FaxNumber: | 9516749635 | ||||||||
| Practice Location | |||||||||
| Address1: | 30414 TOWN CENTER DR APT 321 | ||||||||
| Address2: | |||||||||
| City: | MENIFEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925846872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514341350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2016 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.