Provider Demographics
NPI:1851820864
Name:MCDANIEL, LATITIA RENEE
Entity Type:Individual
Prefix:
First Name:LATITIA
Middle Name:RENEE
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 WOODMONT PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-5727
Mailing Address - Country:US
Mailing Address - Phone:318-780-5501
Mailing Address - Fax:
Practice Address - Street 1:809 POLK ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2452
Practice Address - Country:US
Practice Address - Phone:318-621-0910
Practice Address - Fax:318-621-0918
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty