Provider Demographics
NPI:1063988814
Name:STANBACK, LATASHA YVONNE (PHD)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:YVONNE
Last Name:STANBACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LATASHA
Other - Middle Name:
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:27777 INKSTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4177 RAINBOW DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-2224
Practice Address - Country:US
Practice Address - Phone:404-542-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004260103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist