Basic Information
| Provider Information | |||||||||
| NPI: | 1720599756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARLEY | ||||||||
| FirstName: | LATANEIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3751 CRESTVIEW DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711196525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184022014 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3003 KNIGHT ST STE 115 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711052561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182278390 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2017 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.