Provider Demographics
NPI:1982747630
Name:BURNETT, LATASHA RENEE (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:RENEE
Last Name:BURNETT
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 NW ARLINGTON AVE
Mailing Address - Street 2:SUITE#E
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-6570
Mailing Address - Country:US
Mailing Address - Phone:580-699-8680
Mailing Address - Fax:580-699-8681
Practice Address - Street 1:1201 NW ARLINGTON AVE
Practice Address - Street 2:SUITE#E
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-6570
Practice Address - Country:US
Practice Address - Phone:580-699-8680
Practice Address - Fax:580-699-8681
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2012-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK938106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200343820AMedicaid
OK452556312OtherTRICARE