Provider Demographics
NPI:1902901770
Name:FONTANA, LATISHA LOUISE (MED LPC)
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:LOUISE
Last Name:FONTANA
Suffix:
Gender:F
Credentials:MED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 HIGHWAY 109
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GROVER
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1162
Mailing Address - Country:US
Mailing Address - Phone:636-458-0002
Mailing Address - Fax:636-458-0002
Practice Address - Street 1:2646 HIGHWAY 109
Practice Address - Street 2:SUITE 200
Practice Address - City:GROVER
Practice Address - State:MO
Practice Address - Zip Code:63040-1162
Practice Address - Country:US
Practice Address - Phone:636-458-0002
Practice Address - Fax:636-458-0002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCS001907101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health