Healthcare Provider Details

I. General information

NPI: 1255088563
Provider Name (Legal Business Name): LATARA ANDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 07/16/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 HASLER VALLEY RD
GALLUP NM
87301
US

IV. Provider business mailing address

599 SIESTA KEY AVE
TAVARES FL
32778-5911
US

V. Phone/Fax

Practice location:
  • Phone: 505-413-3447
  • Fax:
Mailing address:
  • Phone: 786-925-8434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW19622
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0420
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: