Provider Demographics
NPI:1649519067
Name:WILKS, LA'TICIA
Entity type:Individual
Prefix:
First Name:LA'TICIA
Middle Name:
Last Name:WILKS
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:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-0959
Mailing Address - Country:US
Mailing Address - Phone:509-575-4084
Mailing Address - Fax:509-225-6313
Practice Address - Street 1:2715 SAINT ANDREWS LOOP
Practice Address - Street 2:SUITE C
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3386
Practice Address - Country:US
Practice Address - Phone:509-412-1051
Practice Address - Fax:509-225-6313
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor