Provider Demographics
NPI:1164856779
Name:BACON, LATOYA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 LAUREL BOWIE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1715
Mailing Address - Country:US
Mailing Address - Phone:240-245-4370
Mailing Address - Fax:240-245-4472
Practice Address - Street 1:6915 LAUREL BOWIE RD STE 205
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1715
Practice Address - Country:US
Practice Address - Phone:240-245-4370
Practice Address - Fax:240-245-4472
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist