Provider Demographics
NPI:1982142105
Name:WITHROW, LATANYA
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:
Last Name:WITHROW
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 1:53 BEACON TER
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01119-2036
Mailing Address - Country:US
Mailing Address - Phone:413-686-4791
Mailing Address - Fax:
Practice Address - Street 1:BAYSTATE MEDICAL CENTER PEDIATRICS
Practice Address - Street 2:140 HIGH STREET
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-0001
Practice Address - Country:US
Practice Address - Phone:413-794-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health