Provider Demographics
NPI:1215633565
Name:SMITH, LATOYA RENEA
Entity type:Individual
Prefix:MRS
First Name:LATOYA
Middle Name:RENEA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8465
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:12093 GAYTON RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23238-3401
Practice Address - Country:US
Practice Address - Phone:804-265-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional