Provider Demographics
NPI:1568176717
Name:OMNI ADDICTION SERVICES
Entity Type:Organization
Organization Name:OMNI ADDICTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LATESHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LSATP
Authorized Official - Phone:434-532-2001
Mailing Address - Street 1:199 MORRIS TOWN CIR
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:VA
Mailing Address - Zip Code:23950-2054
Mailing Address - Country:US
Mailing Address - Phone:434-532-2001
Mailing Address - Fax:
Practice Address - Street 1:102 E HICKS ST STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23868-1830
Practice Address - Country:US
Practice Address - Phone:434-253-5617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty