MEDICARE: MRS. LATIESHA DAVIS WIGGINS CSAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0710103279	VA
2	101YM0800X	Mental Health Counselor	0704015011	VA

General Provider Information

NPI Number	:	1851880827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATIESHA DAVIS WIGGINS CSAC

Provider Business Mailing Address
First Line	:	5750 CHESAPEAKE BLVD STE 105
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-5325
Country	:	US
Telephone Number	:	757-276-3331
Fax Number	:	757-282-7866

Provider Business Practice Location Address
First Line	:	5750 CHESAPEAKE BLVD STE 105
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-5325
Country	:	US
Telephone Number	:	757-966-1728
Fax Number	:	757-282-7866

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2018
Last Update Date	:	04/14/2024

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