Provider Demographics
NPI:1063631331
Name:MCILWAINE, LATASHA SHAWNTAY (MA, MHA, LPC, LCAS)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:SHAWNTAY
Last Name:MCILWAINE
Suffix:
Gender:F
Credentials:MA, MHA, LPC, LCAS
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 743
Mailing Address - Street 2:
Mailing Address - City:PAW CREEK
Mailing Address - State:NC
Mailing Address - Zip Code:28130-0743
Mailing Address - Country:US
Mailing Address - Phone:704-340-4666
Mailing Address - Fax:704-969-7298
Practice Address - Street 1:1409 EAST BLVD
Practice Address - Street 2:SUITE 6B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5817
Practice Address - Country:US
Practice Address - Phone:704-340-4666
Practice Address - Fax:704-969-7298
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2009-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NC6691101YP2500X
NC1296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103719Medicaid