Healthcare Provider Details

I. General information

NPI: 1902106131
Provider Name (Legal Business Name): LATISHIA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6171 W CHARLESTON BLVD
LAS VEGAS NV
89146-1126
US

IV. Provider business mailing address

3712 GRAMERCY AVE
NORTH LAS VEGAS NV
89031-2036
US

V. Phone/Fax

Practice location:
  • Phone: 702-486-6151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: