Provider Demographics
NPI:1104533546
Name:HARRIS-BOYD, LATESHA (LCSW)
Entity type:Individual
Prefix:
First Name:LATESHA
Middle Name:
Last Name:HARRIS-BOYD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4146
Mailing Address - Country:US
Mailing Address - Phone:312-746-5905
Mailing Address - Fax:312-746-4491
Practice Address - Street 1:1105 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4146
Practice Address - Country:US
Practice Address - Phone:312-746-5905
Practice Address - Fax:312-746-4491
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL62153084771HMedicaid