Provider Demographics
NPI:1407621816
Name:ELLIOTT, LATOYA NICOLE
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:NICOLE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATOYA
Other - Middle Name:NICOLE
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6732 LONGLEAF BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-4228
Mailing Address - Country:US
Mailing Address - Phone:904-310-2340
Mailing Address - Fax:
Practice Address - Street 1:2140 KINGSLEY AVE STE 2
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5129
Practice Address - Country:US
Practice Address - Phone:904-375-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health