Provider Demographics
NPI:1609227073
Name:CHRISTENSEN, LATISHA S (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:LATISHA
Middle Name:S
Last Name:CHRISTENSEN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 BESSIE COLEMAN BLVD UNIT 22352
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-9096
Mailing Address - Country:US
Mailing Address - Phone:410-670-5889
Mailing Address - Fax:877-441-2845
Practice Address - Street 1:6232 SAVANNAH BREEZE CT APT 202
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4092
Practice Address - Country:US
Practice Address - Phone:470-670-5889
Practice Address - Fax:877-441-2845
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD199151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1145819Medicaid