Provider Demographics
NPI:1174057145
Name:PRADO, SHANTALL
Entity type:Individual
Prefix:
First Name:SHANTALL
Middle Name:
Last Name:PRADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:90743-0161
Mailing Address - Country:US
Mailing Address - Phone:424-210-5444
Mailing Address - Fax:
Practice Address - Street 1:2301 HYPERION AVE #A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:310-879-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 171M00000X
CA1180201041C0700X
CAASW95838101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator