Provider Demographics
NPI:1043974561
Name:GRENADA, LATICIA
Entity Type:Individual
Prefix:
First Name:LATICIA
Middle Name:
Last Name:GRENADA
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 940165
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-0165
Mailing Address - Country:US
Mailing Address - Phone:347-224-2177
Mailing Address - Fax:
Practice Address - Street 1:3033 GODWIN TER APT 4C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5344
Practice Address - Country:US
Practice Address - Phone:646-204-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health