Healthcare Provider Details

I. General information

NPI: 1699131896
Provider Name (Legal Business Name): DEITRA LATRICE FANT MA,NCC,LCPC,LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 09/29/2026
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WATERFRONT ST STE 420
OXON HILL MD
20745-1122
US

IV. Provider business mailing address

120 WATERFRONT ST STE 420
OXON HILL MD
20745-1122
US

V. Phone/Fax

Practice location:
  • Phone: 703-857-5354
  • Fax: 571-601-4607
Mailing address:
  • Phone: 703-857-5354
  • Fax: 571-601-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC10267
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC15297
License Number StateDC
# 7
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC10267
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701009874
License Number StateVA
# 9
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number08861
License Number StateLA
# 10
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: