Provider Demographics
NPI:1821490285
Name:DEJEAN, LATESHA
Entity Type:Individual
Prefix:MISS
First Name:LATESHA
Middle Name:
Last Name:DEJEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LATESHA
Other - Middle Name:
Other - Last Name:DEJEAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSED
Mailing Address - Street 1:240 MACDOUGAL ST
Mailing Address - Street 2:APT#1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-2803
Mailing Address - Country:US
Mailing Address - Phone:917-860-3457
Mailing Address - Fax:
Practice Address - Street 1:240 MACDOUGAL ST
Practice Address - Street 2:APT#1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-2803
Practice Address - Country:US
Practice Address - Phone:917-860-3457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY847277141252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency