Provider Demographics
NPI:1104577220
Name:WILLIAMS-GOODMAN, LATRACESHA C
Entity type:Individual
Prefix:
First Name:LATRACESHA
Middle Name:C
Last Name:WILLIAMS-GOODMAN
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 1:125 POPLAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15235-3764
Mailing Address - Country:US
Mailing Address - Phone:412-620-8909
Mailing Address - Fax:
Practice Address - Street 1:125 POPLAR RIDGE DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15235-3764
Practice Address - Country:US
Practice Address - Phone:412-620-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA62823601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health