Provider Demographics
NPI:1801124185
Name:BROWN, LATASHIA
Entity type:Individual
Prefix:
First Name:LATASHIA
Middle Name:
Last Name:BROWN
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 1:28 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1023
Mailing Address - Country:US
Mailing Address - Phone:815-304-5534
Mailing Address - Fax:
Practice Address - Street 1:28 N WEST AVE
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1023
Practice Address - Country:US
Practice Address - Phone:815-304-5534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB35053880808222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist