Provider Demographics
NPI:1346600921
Name:MCDONALD, LATASHA
Entity Type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:
Last Name:MCDONALD
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 1:1365 NORTH F ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-0123
Mailing Address - Country:US
Mailing Address - Phone:909-677-8065
Mailing Address - Fax:
Practice Address - Street 1:1365 NORTH F STREET
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-0123
Practice Address - Country:US
Practice Address - Phone:909-677-8065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4263-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)