Provider Demographics
NPI:1124834197
Name:LATAILLE, ASHLEY C (LCDP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:C
Last Name:LATAILLE
Suffix:
Gender:F
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 SEFTON AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-8327
Mailing Address - Country:US
Mailing Address - Phone:401-516-5300
Mailing Address - Fax:
Practice Address - Street 1:205 HALLENE RD STE 102
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2451
Practice Address - Country:US
Practice Address - Phone:401-737-4788
Practice Address - Fax:401-736-5299
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00999101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)