Provider Demographics
NPI:1811131691
Name:DICKENSON-LATHAM, NATIESHA TAMUE (MACCCSLP)
Entity type:Individual
Prefix:MRS
First Name:NATIESHA
Middle Name:TAMUE
Last Name:DICKENSON-LATHAM
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14861 262ND PL
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3039
Mailing Address - Country:US
Mailing Address - Phone:718-712-2323
Mailing Address - Fax:718-712-2323
Practice Address - Street 1:1253 E 103RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4501
Practice Address - Country:US
Practice Address - Phone:917-887-7421
Practice Address - Fax:718-712-2323
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0128641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist