Provider Demographics
NPI:1508366709
Name:ALLEN, LATESCHA TANAE (CDCA)
Entity Type:Individual
Prefix:
First Name:LATESCHA
Middle Name:TANAE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 LIBERTY BELL CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7925
Mailing Address - Country:US
Mailing Address - Phone:937-301-9508
Mailing Address - Fax:
Practice Address - Street 1:200 DARUMA PKWY
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-7909
Practice Address - Country:US
Practice Address - Phone:937-262-3502
Practice Address - Fax:937-496-5274
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH100128101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)