Provider Demographics
NPI:1215090626
Name:LATSHA, MELODY ANN (BCD, LCSW,)
Entity type:Individual
Prefix:MS
First Name:MELODY
Middle Name:ANN
Last Name:LATSHA
Suffix:
Gender:F
Credentials:BCD, LCSW,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801-1801
Mailing Address - Country:US
Mailing Address - Phone:570-286-7633
Mailing Address - Fax:570-988-2876
Practice Address - Street 1:211 N 2ND ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-1801
Practice Address - Country:US
Practice Address - Phone:570-286-7633
Practice Address - Fax:570-988-2876
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CW013727101YM0800X
PACW013727104100000X, 1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA844204Medicare ID - Type UnspecifiedSOCIAL WORKER
PA800006792Medicare ID - Type UnspecifiedSOCIAL WORKER