Provider Demographics
NPI:1912782137
Name:WILSON, LATARA A (MA, CMHA)
Entity Type:Individual
Prefix:
First Name:LATARA
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 NE 7TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1632
Mailing Address - Country:US
Mailing Address - Phone:541-507-6400
Mailing Address - Fax:
Practice Address - Street 1:777 NE 7TH ST STE 205
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1632
Practice Address - Country:US
Practice Address - Phone:541-507-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health