Provider Demographics
NPI:1023564101
Name:ABRAHAM, LATASHA (LPC)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:ABRAHAM
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 1:4210 COLUMBIA RD
Mailing Address - Street 2:SUITE 5D
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4210 COLUMBIA RD
Practice Address - Street 2:SUITE 5D
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0401
Practice Address - Country:US
Practice Address - Phone:706-836-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009282101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health