Provider Demographics
NPI:1417763996
Name:ANDERSON, LATORIA ROCKWELL
Entity type:Individual
Prefix:
First Name:LATORIA
Middle Name:ROCKWELL
Last Name:ANDERSON
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 1:949 RICHLAND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3007
Mailing Address - Country:US
Mailing Address - Phone:919-690-5308
Mailing Address - Fax:
Practice Address - Street 1:111 MACKENAN DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7903
Practice Address - Country:US
Practice Address - Phone:919-371-2824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty