Provider Demographics
NPI:1922356625
Name:DAVIS, LATISHIA RAE (NCC, LPC)
Entity Type:Individual
Prefix:
First Name:LATISHIA
Middle Name:RAE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-2023
Mailing Address - Country:US
Mailing Address - Phone:336-618-6021
Mailing Address - Fax:
Practice Address - Street 1:118 S CHERRY ST STE D
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2764
Practice Address - Country:US
Practice Address - Phone:336-618-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8671101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional