Provider Demographics
NPI:1891139598
Name:FORNEY, LATISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:FORNEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 WINDSHIRE LN
Mailing Address - Street 2:APT. 111
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 HUNTSMAN CT
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-6060
Practice Address - Country:US
Practice Address - Phone:704-589-1104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0081641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical