Provider Demographics
NPI:1285417204
Name:LAMAQUE, SHANTAI
Entity type:Individual
Prefix:
First Name:SHANTAI
Middle Name:
Last Name:LAMAQUE
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 1:15756 LA JOYA PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-2116
Mailing Address - Country:US
Mailing Address - Phone:760-220-2839
Mailing Address - Fax:
Practice Address - Street 1:15756 LA JOYA PL
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-2116
Practice Address - Country:US
Practice Address - Phone:760-220-2839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC13722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health