Provider Demographics
NPI:1013297431
Name:LEWIS, LATISHA SHANTA (MAT)
Entity Type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:SHANTA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 RICHMOND SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3283
Mailing Address - Country:US
Mailing Address - Phone:618-402-4319
Mailing Address - Fax:
Practice Address - Street 1:1948 RICHMOND SPRINGS LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3283
Practice Address - Country:US
Practice Address - Phone:618-402-4319
Practice Address - Fax:618-825-0210
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL200-5377-9925222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist