Provider Demographics
NPI:1750038105
Name:WHITEHEAD, LATARRIA (LAC)
Entity Type:Individual
Prefix:
First Name:LATARRIA
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 OLD BRIDGE TPKE UNIT 1214
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-1938
Mailing Address - Country:US
Mailing Address - Phone:216-482-4016
Mailing Address - Fax:
Practice Address - Street 1:19 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2172
Practice Address - Country:US
Practice Address - Phone:856-985-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health