Provider Demographics
NPI:1730429978
Name:BLISSETT, LATASHA LATRICE (LPC)
Entity type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:LATRICE
Last Name:BLISSETT
Suffix:
Gender:F
Credentials:LPC
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 962783
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-6928
Mailing Address - Country:US
Mailing Address - Phone:770-331-6576
Mailing Address - Fax:
Practice Address - Street 1:101 DEVANT ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2710
Practice Address - Country:US
Practice Address - Phone:404-465-4244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004448101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty