Provider Demographics
NPI:1487832671
Name:ELLIS, LATASHA MICHELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:MICHELLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:LATASHA
Other - Middle Name:MICHELLE
Other - Last Name:QUAILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:
Practice Address - Street 1:766 HARTNESS RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3425
Practice Address - Country:US
Practice Address - Phone:704-380-3620
Practice Address - Fax:704-380-3623
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-10
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0059511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106903Medicaid
NC2852279Medicare PIN