Provider Demographics
NPI:1568904423
Name:CLAYTON, LATOSHA
Entity Type:Individual
Prefix:
First Name:LATOSHA
Middle Name:
Last Name:CLAYTON
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 1:3526 BURLINGTON DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-1983
Mailing Address - Country:US
Mailing Address - Phone:205-862-2520
Mailing Address - Fax:205-841-9432
Practice Address - Street 1:3526 BURLINGTON DR
Practice Address - Street 2:SUITE 1
Practice Address - City:FULTONDALE
Practice Address - State:AL
Practice Address - Zip Code:35068-1983
Practice Address - Country:US
Practice Address - Phone:205-862-2520
Practice Address - Fax:205-841-9432
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3561101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional