Provider Demographics
NPI:1548713068
Name:WILLIAMS, LATASHA C
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:C
Last Name:WILLIAMS
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 1:505 ROCKMONT CIR SW # 39
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5856
Mailing Address - Country:US
Mailing Address - Phone:678-907-2755
Mailing Address - Fax:
Practice Address - Street 1:1946 BIG BRANCH CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-8951
Practice Address - Country:US
Practice Address - Phone:678-907-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1548713068Medicaid