Provider Demographics
NPI:1093259079
Name:WILLIAMS, LATASHUA
Entity Type:Individual
Prefix:
First Name:LATASHUA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATASHUA
Other - Middle Name:
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21222 VIVIENNE DR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1824
Mailing Address - Country:US
Mailing Address - Phone:708-800-9546
Mailing Address - Fax:
Practice Address - Street 1:21222 VIVIENNE DR
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1824
Practice Address - Country:US
Practice Address - Phone:708-800-9546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-11
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician