Provider Demographics
NPI:1649789181
Name:HUMPHRIES, LATISHA
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:HUMPHRIES
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 1:750 PORT ST APT 229
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 PORT ST APT 204
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2475
Practice Address - Country:US
Practice Address - Phone:412-522-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst