Provider Demographics
NPI:1710740782
Name:BEAVERS, LATORIA CHERRELLE
Entity Type:Individual
Prefix:
First Name:LATORIA
Middle Name:CHERRELLE
Last Name:BEAVERS
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 315
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36850-0315
Mailing Address - Country:US
Mailing Address - Phone:334-401-8172
Mailing Address - Fax:
Practice Address - Street 1:5900 WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-4362
Practice Address - Country:US
Practice Address - Phone:706-786-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-24-325226106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician