Healthcare Provider Details

I. General information

NPI: 1659934594
Provider Name (Legal Business Name): LATISHA NICOLE SEALEY LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 E BROAD ST
STATESVILLE NC
28677-5325
US

IV. Provider business mailing address

12025 BROWNESTONE VIEW DR
CHARLOTTE NC
28269-7198
US

V. Phone/Fax

Practice location:
  • Phone: 980-430-9205
  • Fax:
Mailing address:
  • Phone: 614-212-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA14501
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA14501
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: