Provider Demographics
NPI:1033659826
Name:MILES, LATARA (MA)
Entity Type:Individual
Prefix:MRS
First Name:LATARA
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 EE WALLACE BLVD S
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-3224
Mailing Address - Country:US
Mailing Address - Phone:318-757-9363
Mailing Address - Fax:
Practice Address - Street 1:615 EE WALLACE BLVD S
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-3224
Practice Address - Country:US
Practice Address - Phone:318-757-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13763101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health