Provider Demographics
NPI:1497192447
Name:EVERETT, LATOYA JENELLE (MSW)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:JENELLE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-2101
Mailing Address - Country:US
Mailing Address - Phone:407-323-2036
Mailing Address - Fax:407-324-0716
Practice Address - Street 1:919 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2101
Practice Address - Country:US
Practice Address - Phone:407-323-2036
Practice Address - Fax:407-324-0716
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1164581633Medicaid