Provider Demographics
NPI:1265609747
Name:DELANEY, LATASHA
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:DELANEY
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 1:312 N MISSOURI ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-3186
Mailing Address - Country:US
Mailing Address - Phone:870-907-9185
Mailing Address - Fax:870-561-5311
Practice Address - Street 1:312 N MISSOURI ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3186
Practice Address - Country:US
Practice Address - Phone:870-907-9185
Practice Address - Fax:870-561-5311
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1608105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR290592744Medicaid
AR228466719Medicaid