Provider Demographics
NPI:1366124836
Name:GREENE, LATASHA D
Entity type:Individual
Prefix:DR
First Name:LATASHA
Middle Name:D
Last Name:GREENE
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 1:502 N CARROLL AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6449
Mailing Address - Country:US
Mailing Address - Phone:682-292-7012
Mailing Address - Fax:
Practice Address - Street 1:502 N CARROLL AVE STE 120
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6449
Practice Address - Country:US
Practice Address - Phone:682-292-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty