Healthcare Provider Details

I. General information

NPI: 1770092884
Provider Name (Legal Business Name): LATASHA MARIE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 PEACH STREET
ERIE PA
16509
US

IV. Provider business mailing address

5100 PEACH STREET
ERIE PA
16509
US

V. Phone/Fax

Practice location:
  • Phone: 814-866-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW133856
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: