Provider Demographics
NPI:1649746371
Name:ADEKUNLE, LATHONIA
Entity Type:Individual
Prefix:MS
First Name:LATHONIA
Middle Name:
Last Name:ADEKUNLE
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 1:1620 OLDE SPRING TRL
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2749
Mailing Address - Country:US
Mailing Address - Phone:770-309-1658
Mailing Address - Fax:
Practice Address - Street 1:2300 HERODIAN WAY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:770-309-1658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-20
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
GA171M00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1649746371Medicaid