Provider Demographics
NPI:1376994483
Name:LEE, LATOYA JANELLE
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:JANELLE
Last Name:LEE
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 1:6823 W PLEASANT LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2660
Mailing Address - Country:US
Mailing Address - Phone:602-686-0419
Mailing Address - Fax:
Practice Address - Street 1:6823 W PLEASANT LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2660
Practice Address - Country:US
Practice Address - Phone:602-686-0419
Practice Address - Fax:602-612-3069
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH8438374U00000X, 322D00000X, 106S00000X
AZBH4867101YP2500X, 103K00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children