Provider Demographics
NPI:1962292367
Name:MACK, LATAVIA
Entity type:Individual
Prefix:MISS
First Name:LATAVIA
Middle Name:
Last Name:MACK
Suffix:
Gender:
Credentials:
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 485
Mailing Address - Street 2:
Mailing Address - City:BOWMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29018-0485
Mailing Address - Country:US
Mailing Address - Phone:803-596-8651
Mailing Address - Fax:
Practice Address - Street 1:120 OAK ST
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:SC
Practice Address - Zip Code:29018
Practice Address - Country:US
Practice Address - Phone:803-596-8651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst