Provider Demographics
NPI:1528703980
Name:BROWN, LATISHA RACHELLE
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:RACHELLE
Last Name:BROWN
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 1:370 FENBROOK WAY SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1680
Mailing Address - Country:US
Mailing Address - Phone:425-465-8440
Mailing Address - Fax:
Practice Address - Street 1:370 FENBROOK WAY SW # 30064
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1680
Practice Address - Country:US
Practice Address - Phone:425-465-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TH0100X
GA103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service