Provider Demographics
NPI:1356129480
Name:GHOLAR, LATASHA
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:GHOLAR
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 1:1401 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-2633
Mailing Address - Country:US
Mailing Address - Phone:601-395-7540
Mailing Address - Fax:
Practice Address - Street 1:1401 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2633
Practice Address - Country:US
Practice Address - Phone:601-395-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 171W00000X, 376J00000X, 376K00000X, 385HR2055X, 374U00000X, 385HR2065X
MS374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171W00000XOther Service ProvidersContractor
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child