Provider Demographics
NPI:1225413628
Name:FOURCELL, LATRECIA (TEACHER)
Entity Type:Individual
Prefix:
First Name:LATRECIA
Middle Name:
Last Name:FOURCELL
Suffix:
Gender:F
Credentials:TEACHER
Other - Prefix:
Other - First Name:LATRECIA
Other - Middle Name:
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1901 LORING PL S
Mailing Address - Street 2:APT 5B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-1927
Mailing Address - Country:US
Mailing Address - Phone:347-208-8768
Mailing Address - Fax:
Practice Address - Street 1:1901 LORING PL S
Practice Address - Street 2:APT 5B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-1927
Practice Address - Country:US
Practice Address - Phone:347-208-8768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY945611151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist