Provider Demographics
NPI:1235706607
Name:LAVALLAIS-MADISON, LATASHANNA (MA,LE)
Entity type:Individual
Prefix:
First Name:LATASHANNA
Middle Name:
Last Name:LAVALLAIS-MADISON
Suffix:
Gender:F
Credentials:MA,LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 E EXPOSITION AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-5033
Mailing Address - Country:US
Mailing Address - Phone:303-777-1151
Mailing Address - Fax:
Practice Address - Street 1:3955 E EXPOSITION AVE STE 320
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-5033
Practice Address - Country:US
Practice Address - Phone:303-777-1151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCOZ.0708525405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty