Provider Demographics
NPI:1164669149
Name:PARKER, LATIA R (LADC, LPC)
Entity Type:Individual
Prefix:
First Name:LATIA
Middle Name:R
Last Name:PARKER
Suffix:
Gender:F
Credentials:LADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W HOBSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-3926
Mailing Address - Country:US
Mailing Address - Phone:918-902-5348
Mailing Address - Fax:918-224-6837
Practice Address - Street 1:2508 E 71ST ST
Practice Address - Street 2:SUITE C
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5572
Practice Address - Country:US
Practice Address - Phone:918-794-6570
Practice Address - Fax:918-340-5189
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK659101YA0400X
OK3343101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200232480AMedicaid