Provider Demographics
NPI:1124404215
Name:WILLIAMS, LATRESHA
Entity Type:Individual
Prefix:
First Name:LATRESHA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 12TH ST
Mailing Address - Street 2:SUITE 911-A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 12TH ST
Practice Address - Street 2:SUITE 911-A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2462
Practice Address - Country:US
Practice Address - Phone:706-718-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160216AMedicaid