Provider Demographics
NPI:1104593508
Name:LATIMORE, SHRONNA
Entity type:Individual
Prefix:
First Name:SHRONNA
Middle Name:
Last Name:LATIMORE
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 1:6885 SLATE STONE WAY SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5433
Mailing Address - Country:US
Mailing Address - Phone:404-539-6277
Mailing Address - Fax:
Practice Address - Street 1:6885 SLATE STONE WAY SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-5433
Practice Address - Country:US
Practice Address - Phone:404-539-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional