Provider Demographics
NPI:1417338799
Name:AGADA, LATAVIA SHANTAYE (LCSW)
Entity Type:Individual
Prefix:
First Name:LATAVIA
Middle Name:SHANTAYE
Last Name:AGADA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 GLENWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101
Mailing Address - Country:US
Mailing Address - Phone:815-968-5342
Mailing Address - Fax:
Practice Address - Street 1:2823 GLENWOOD AVE.
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101
Practice Address - Country:US
Practice Address - Phone:815-968-5342
Practice Address - Fax:815-968-4656
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150015210104100000X
IL149.0184941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker