Provider Demographics
NPI:1417692872
Name:ROLES, LATASHA GENELL (LGPC)
Entity Type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:GENELL
Last Name:ROLES
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4022 DUDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-2139
Mailing Address - Country:US
Mailing Address - Phone:443-208-6156
Mailing Address - Fax:
Practice Address - Street 1:1900 N HOWARD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5909
Practice Address - Country:US
Practice Address - Phone:443-438-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12518101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health