Provider Demographics
NPI:1568969202
Name:MATLOCK, LATISHA
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2118
Mailing Address - Country:US
Mailing Address - Phone:614-294-2661
Mailing Address - Fax:
Practice Address - Street 1:1515 INDIANOLA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2118
Practice Address - Country:US
Practice Address - Phone:614-294-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor