Provider Demographics
NPI:1265674493
Name:MCLEAN, LATONJA RENEE
Entity Type:Individual
Prefix:MS
First Name:LATONJA
Middle Name:RENEE
Last Name:MCLEAN
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 1:1214 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-3410
Mailing Address - Country:US
Mailing Address - Phone:336-354-3886
Mailing Address - Fax:
Practice Address - Street 1:1214 GROVE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-3410
Practice Address - Country:US
Practice Address - Phone:336-354-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
24338101YA0400X
251E00000X
NCA15130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251E00000XAgenciesHome Health