Healthcare Provider Details

I. General information

NPI: 1194656843
Provider Name (Legal Business Name): MISS LATEISHA ABERNATHY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N SAN JOAQUIN ST
STOCKTON CA
95202-2954
US

IV. Provider business mailing address

1619 BRIDLE PATH APT 246
STOCKTON CA
95210-6693
US

V. Phone/Fax

Practice location:
  • Phone: 209-993-7663
  • Fax:
Mailing address:
  • Phone: 209-284-7098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: