Provider Demographics
NPI:1104167832
Name:VITEMB, SHAYNE ANN (LMFT)
Entity type:Individual
Prefix:
First Name:SHAYNE
Middle Name:ANN
Last Name:VITEMB
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W GRAND AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3700
Mailing Address - Country:US
Mailing Address - Phone:310-227-0201
Mailing Address - Fax:310-726-1030
Practice Address - Street 1:302 W GRAND AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3700
Practice Address - Country:US
Practice Address - Phone:310-227-0201
Practice Address - Fax:310-726-1030
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC#51827101YM0800X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst