Provider Demographics
NPI:1578330395
Name:MOORE, LATRINA LAVELL
Entity Type:Individual
Prefix:
First Name:LATRINA
Middle Name:LAVELL
Last Name:MOORE
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 1:201 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4185
Mailing Address - Country:US
Mailing Address - Phone:773-503-6021
Mailing Address - Fax:
Practice Address - Street 1:201 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4185
Practice Address - Country:US
Practice Address - Phone:773-503-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178019649101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional