Provider Demographics
NPI:1619218625
Name:MCINNIS, LATESHA TANISE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LATESHA
Middle Name:TANISE
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 POPPS FERRY RD APT 1127BB
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2031
Mailing Address - Country:US
Mailing Address - Phone:228-313-6072
Mailing Address - Fax:
Practice Address - Street 1:1955 POPPS FERRY RD APT 1127BB
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2031
Practice Address - Country:US
Practice Address - Phone:228-313-6072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC75531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical