Provider Demographics
NPI:1386491777
Name:LANDRUM, LATRICIA RENEE
Entity type:Individual
Prefix:
First Name:LATRICIA
Middle Name:RENEE
Last Name:LANDRUM
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 1:5724 ARBOR STATION RD APT D
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-4664
Mailing Address - Country:US
Mailing Address - Phone:251-508-1902
Mailing Address - Fax:
Practice Address - Street 1:4171 LOMAC ST STE F1127
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2945
Practice Address - Country:US
Practice Address - Phone:251-508-1902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLPC05244101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional