Provider Demographics
NPI:1164635389
Name:DULLIVAN, LATASHA REED (MS)
Entity Type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:REED
Last Name:DULLIVAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 WOODGATE WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0536
Mailing Address - Country:US
Mailing Address - Phone:850-251-1454
Mailing Address - Fax:850-487-0045
Practice Address - Street 1:1524 WOODGATE WAY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0536
Practice Address - Country:US
Practice Address - Phone:850-251-1454
Practice Address - Fax:850-487-0045
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker