Provider Demographics
NPI:1679244453
Name:WILLIAMS, LATELDRIN DENISE (LMSW, CSW)
Entity Type:Individual
Prefix:MRS
First Name:LATELDRIN
Middle Name:DENISE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MICHIGAN AVE STE 335
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5614
Mailing Address - Country:US
Mailing Address - Phone:573-673-8434
Mailing Address - Fax:
Practice Address - Street 1:128 TRILLIUM CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2148
Practice Address - Country:US
Practice Address - Phone:859-379-8195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10772104100000X
KY256167104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty