Provider Demographics
NPI:1386936631
Name:DUDLEY, LATASHA (BBA, M ED)
Entity type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:BBA, M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ALTON DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-1879
Mailing Address - Country:US
Mailing Address - Phone:404-397-8907
Mailing Address - Fax:770-726-9645
Practice Address - Street 1:3275 HUNTING CREEK PASS
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8469
Practice Address - Country:US
Practice Address - Phone:678-927-5159
Practice Address - Fax:770-726-9645
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA429007101YS0200X
171M00000X, 225CA2400X, 101Y00000X
GA225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner