Provider Demographics
NPI:1750818761
Name:LONG, LATASHA D
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:D
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12097 OLD HAMMOND HWY STE I2
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8679
Mailing Address - Country:US
Mailing Address - Phone:225-831-9249
Mailing Address - Fax:225-831-9248
Practice Address - Street 1:12097 OLD HAMMOND HWY STE I2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816
Practice Address - Country:US
Practice Address - Phone:225-831-9249
Practice Address - Fax:225-831-9248
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1255705828Medicaid