Basic Information
| Provider Information | |||||||||
| NPI: | 1750818761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | LATASHA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LONG | ||||||||
| OtherFirstName: | LATASHA | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12097 OLD HAMMOND HWY STE I2 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708168679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2258319249 | ||||||||
| FaxNumber: | 2258319248 | ||||||||
| Practice Location | |||||||||
| Address1: | 12097 OLD HAMMOND HWY STE I2 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2258319249 | ||||||||
| FaxNumber: | 2258319248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2017 | ||||||||
| LastUpdateDate: | 01/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1255705828 | 05 | LA | MEDICAID |