Provider Demographics
NPI:1629382924
Name:THOMAS, LATASHA N
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:N
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:N
Other - Last Name:PEACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 SAINT PATRICKS DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4527
Mailing Address - Country:US
Mailing Address - Phone:301-870-7366
Mailing Address - Fax:301-870-6717
Practice Address - Street 1:10401 HOSPITAL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3110
Practice Address - Country:US
Practice Address - Phone:301-856-0050
Practice Address - Fax:301-856-0518
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD196518200Medicaid