Provider Demographics
NPI:1972395960
Name:PROVITT, LATESHIA NATIA (ALC)
Entity type:Individual
Prefix:MS
First Name:LATESHIA
Middle Name:NATIA
Last Name:PROVITT
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9153 SAW TOOTH LOOP
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-2374
Mailing Address - Country:US
Mailing Address - Phone:334-467-4983
Mailing Address - Fax:
Practice Address - Street 1:1785 TALIAFERRO TRL STE 13
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7758
Practice Address - Country:US
Practice Address - Phone:334-467-4983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC05234101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor