Provider Demographics
NPI:1346438421
Name:DANIEL, LATISHA R (LPCC)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:R
Last Name:DANIEL
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:LATISHA
Other - Middle Name:R
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:341 BOGLE STREET STE A
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2815
Practice Address - Country:US
Practice Address - Phone:606-677-0201
Practice Address - Fax:606-677-0208
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY172163101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
13975265OtherCAQH
KY7100449230Medicaid