Provider Demographics
NPI:1124615646
Name:POWELL, LATESHA DENISE (LLPC)
Entity type:Individual
Prefix:
First Name:LATESHA
Middle Name:DENISE
Last Name:POWELL
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7819 NECKEL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1140
Mailing Address - Country:US
Mailing Address - Phone:313-346-6924
Mailing Address - Fax:
Practice Address - Street 1:5728 SCHAEFER RD STE 204
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2287
Practice Address - Country:US
Practice Address - Phone:313-354-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017533101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional