Provider Demographics
NPI:1588785455
Name:KEITH, LATISHA
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:KEITH
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 1:6456 BLARNEY STONE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7116 FORT HUNT RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307-1900
Practice Address - Country:US
Practice Address - Phone:703-768-0234
Practice Address - Fax:703-768-2697
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003784225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist