Provider Demographics
NPI:1164050720
Name:BRANCH, LATARA SHARI
Entity Type:Individual
Prefix:
First Name:LATARA
Middle Name:SHARI
Last Name:BRANCH
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 1:111 MACKENAN DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7903
Mailing Address - Country:US
Mailing Address - Phone:910-747-0337
Mailing Address - Fax:
Practice Address - Street 1:6223 TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-7306
Practice Address - Country:US
Practice Address - Phone:910-747-0337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty