Basic Information
| Provider Information | |||||||||
| NPI: | 1447784970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | LATONYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 644 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712204619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182393862 | ||||||||
| FaxNumber: | 3182393867 | ||||||||
| Practice Location | |||||||||
| Address1: | 644 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182393862 | ||||||||
| FaxNumber: | 3182393867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2017 | ||||||||
| LastUpdateDate: | 06/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 103K00000X | LA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1558770867 | 05 | LA | MEDICAID |