Provider Demographics
NPI:1336823657
Name:STANIFER-LUMPKIN, LATASHA
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:STANIFER-LUMPKIN
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 1:4518 HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3320
Mailing Address - Country:US
Mailing Address - Phone:612-807-6309
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1789
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306689101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)