Provider Demographics
NPI:1063926715
Name:HITCHCOCK, LATARSA RENEE
Entity type:Individual
Prefix:
First Name:LATARSA
Middle Name:RENEE
Last Name:HITCHCOCK
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 1:2015 GUM BRANCH RD APT 810
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-5072
Mailing Address - Country:US
Mailing Address - Phone:910-581-5960
Mailing Address - Fax:
Practice Address - Street 1:2015 GUM BRANCH RD APT 810
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5072
Practice Address - Country:US
Practice Address - Phone:910-581-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health