Provider Demographics
NPI:1356678320
Name:GAINES, LA-TOYA SHANNELLE (PSYD LP)
Entity Type:Individual
Prefix:MRS
First Name:LA-TOYA
Middle Name:SHANNELLE
Last Name:GAINES
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29532 SOUTHFIELD RD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2023
Mailing Address - Country:US
Mailing Address - Phone:313-449-3913
Mailing Address - Fax:
Practice Address - Street 1:29532 SOUTHFIELD RD
Practice Address - Street 2:SUITE #101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2023
Practice Address - Country:US
Practice Address - Phone:313-449-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015276103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent