Provider Demographics
NPI:1407145527
Name:GARRISON, LATRESHA G (MED, LCPC)
Entity Type:Individual
Prefix:
First Name:LATRESHA
Middle Name:G
Last Name:GARRISON
Suffix:
Gender:F
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320024
Mailing Address - Street 2:
Mailing Address - City:GLEN
Mailing Address - State:MT
Mailing Address - Zip Code:59732-0024
Mailing Address - Country:US
Mailing Address - Phone:406-683-6801
Mailing Address - Fax:406-835-3572
Practice Address - Street 1:23 S. IDAHO #2
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725
Practice Address - Country:US
Practice Address - Phone:406-683-6801
Practice Address - Fax:406-835-3572
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1548 LCPC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional