Provider Demographics
NPI:1770779969
Name:O NEAL, LATISHA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:ANN
Last Name:O NEAL
Suffix:
Gender:F
Credentials:LCSW
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 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-2101
Practice Address - Street 1:102 W KENWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4379
Practice Address - Country:US
Practice Address - Phone:217-872-3800
Practice Address - Fax:217-872-0849
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0176891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical