Provider Demographics
NPI:1629624382
Name:LATELLA, MIKE (CADC-II)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:LATELLA
Suffix:
Gender:M
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PETROL PT STE A-3
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1550
Mailing Address - Country:US
Mailing Address - Phone:678-568-9049
Mailing Address - Fax:
Practice Address - Street 1:111 PETROL PT STE A-3
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1550
Practice Address - Country:US
Practice Address - Phone:678-568-9049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1241101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3918OtherGA CERTIFIED DRUG AND ALCOHOL EVALUATOR NUMBER
GAEO56OtherCERTIFIED TELE-MEDICAL ELECTRONIC DRUG AND ALCOHOL COUNSELOR
GA1241OtherGA CERTIFIED ALCOHOL AND DRUG COUNSELOR LEVEL II NUMBER
GA809429OtherINTERNATIONALLY CERTIFIED ALCOHOL AND DRUG COUNSELOR