Provider Demographics
NPI:1346703329
Name:COLLINS, LATRESHA
Entity Type:Individual
Prefix:
First Name:LATRESHA
Middle Name:
Last Name:COLLINS
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 1:3642 VINE SPRINGS TRCE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620-7644
Mailing Address - Country:US
Mailing Address - Phone:601-955-7047
Mailing Address - Fax:
Practice Address - Street 1:1260 UPPER HEMBREE RD STE D
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4611
Practice Address - Country:US
Practice Address - Phone:470-387-0593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty