Provider Demographics
NPI:1689386492
Name:OGISI, LATALIA M (LPA)
Entity Type:Individual
Prefix:
First Name:LATALIA
Middle Name:M
Last Name:OGISI
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EVERGREEN RD STE 102
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1010
Mailing Address - Country:US
Mailing Address - Phone:252-342-0050
Mailing Address - Fax:
Practice Address - Street 1:350 EVERGREEN RD STE 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1010
Practice Address - Country:US
Practice Address - Phone:252-342-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY280558103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical