Provider Demographics
NPI:1841866548
Name:DERYS, LATISHA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:MARIE
Last Name:DERYS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LATISHA
Other - Middle Name:MARIE
Other - Last Name:DERYS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1065 NE 125TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5833
Mailing Address - Country:US
Mailing Address - Phone:888-852-6672
Mailing Address - Fax:305-891-4228
Practice Address - Street 1:7481 W OAKLAND PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-4985
Practice Address - Country:US
Practice Address - Phone:954-771-7743
Practice Address - Fax:954-771-7748
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW181181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty