Provider Demographics
NPI:1669786208
Name:BADER, LATISHA LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:LATISHA
Middle Name:LYNN
Last Name:BADER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LATISHA
Other - Middle Name:LYNN
Other - Last Name:BRADDOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2307 S GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9007
Mailing Address - Country:US
Mailing Address - Phone:405-273-5236
Mailing Address - Fax:405-273-4345
Practice Address - Street 1:2307 S GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-273-5236
Practice Address - Fax:405-273-4345
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1085103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling