Provider Demographics
NPI:1891318671
Name:PENNANT, LATASHA EYVONNE (LGPC)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:EYVONNE
Last Name:PENNANT
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N HOWARD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5909
Mailing Address - Country:US
Mailing Address - Phone:443-438-6742
Mailing Address - Fax:443-773-5624
Practice Address - Street 1:1900 N HOWARD ST STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5909
Practice Address - Country:US
Practice Address - Phone:443-438-6742
Practice Address - Fax:443-773-5624
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MHLGP10440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD38-3876389Medicaid