Provider Demographics
NPI:1508541038
Name:LEWIS, LATORIA MONIEK (LPC-A, NBCC)
Entity Type:Individual
Prefix:
First Name:LATORIA
Middle Name:MONIEK
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPC-A, NBCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 WILLIE HODGE RD
Mailing Address - Street 2:
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-6142
Mailing Address - Country:US
Mailing Address - Phone:843-250-4049
Mailing Address - Fax:
Practice Address - Street 1:441 WILLIE HODGE RD
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6142
Practice Address - Country:US
Practice Address - Phone:843-250-4049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty