Healthcare Provider Details

I. General information

NPI: 1730010109
Provider Name (Legal Business Name): LATISHIA NYCOLE MARSHALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 S ARCHER AVE
CHICAGO IL
60638-1659
US

IV. Provider business mailing address

PO BOX 388556
CHICAGO IL
60638-8556
US

V. Phone/Fax

Practice location:
  • Phone: 708-304-3010
  • Fax:
Mailing address:
  • Phone: 708-304-3010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.118318
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: