Provider Demographics
NPI:1134633993
Name:SMITH, LATISHA (EDS)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S. SMILEY ST.
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 S. SMILEY ST.
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-632-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool