Provider Demographics
NPI:1194131953
Name:STREATER, LAKISHA TOWANDA (LMBT 10697)
Entity type:Individual
Prefix:
First Name:LAKISHA
Middle Name:TOWANDA
Last Name:STREATER
Suffix:
Gender:F
Credentials:LMBT 10697
Other - Prefix:
Other - First Name:LAKISHA
Other - Middle Name:TOWANDA
Other - Last Name:STREATER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMBT 10698
Mailing Address - Street 1:112 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-2781
Mailing Address - Country:US
Mailing Address - Phone:704-690-3597
Mailing Address - Fax:
Practice Address - Street 1:112 S GREEN ST
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2781
Practice Address - Country:US
Practice Address - Phone:704-690-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10697174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist