Provider Demographics
NPI:1467025270
Name:MCMILLER, LATOYA
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:
Last Name:MCMILLER
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:PO BOX 384
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-0384
Mailing Address - Country:US
Mailing Address - Phone:910-729-9659
Mailing Address - Fax:
Practice Address - Street 1:7824 PITTSBORO GOLDSTON RD
Practice Address - Street 2:
Practice Address - City:BEAR CREEK
Practice Address - State:NC
Practice Address - Zip Code:27207-9551
Practice Address - Country:US
Practice Address - Phone:919-898-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-019-073320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities