Provider Demographics
NPI:1275070484
Name:DOMINO, LATOSHA (MED)
Entity Type:Individual
Prefix:
First Name:LATOSHA
Middle Name:
Last Name:DOMINO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58155 CHINN ST
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3601
Mailing Address - Country:US
Mailing Address - Phone:225-385-4543
Mailing Address - Fax:866-825-9703
Practice Address - Street 1:58155 CHINN ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3601
Practice Address - Country:US
Practice Address - Phone:225-385-4543
Practice Address - Fax:866-825-9703
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health