Individual
LATISHA CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
8109 BLACKGUM CT, INDIANAPOLIS, IN 46236-8260
(317) 658-5177
Mailing address
8109 BLACKGUM CT, INDIANAPOLIS, IN 46236-8260
(317) 658-5177
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00000000
LATISHA
IN
Enumeration date
09/11/2020
Last updated
06/30/2022
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