Provider Demographics
NPI:1366704645
Name:MITCHELL, LATASHA
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:MITCHELL
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 1:1928 ROSE CORAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1806
Mailing Address - Country:US
Mailing Address - Phone:702-573-9265
Mailing Address - Fax:
Practice Address - Street 1:1928 ROSE CORAL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-1806
Practice Address - Country:US
Practice Address - Phone:702-573-9265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1402454597103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst