Provider Demographics
NPI:1043787559
Name:FORTEAU, LATASHA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:MARIE
Last Name:FORTEAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7047 GERMANTOWN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1866
Mailing Address - Country:US
Mailing Address - Phone:484-430-4738
Mailing Address - Fax:
Practice Address - Street 1:7047 GERMANTOWN AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119
Practice Address - Country:US
Practice Address - Phone:484-430-4738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0218751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty