Provider Demographics
NPI:1265203772
Name:HARDY, LATIQUA
Entity type:Individual
Prefix:
First Name:LATIQUA
Middle Name:
Last Name:HARDY
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 1:8508 TERRA COTTA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-9545
Mailing Address - Country:US
Mailing Address - Phone:336-254-7113
Mailing Address - Fax:
Practice Address - Street 1:5641 POPLAR TENT RD STE 204
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-7588
Practice Address - Country:US
Practice Address - Phone:704-664-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP020061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty