Provider Demographics
NPI:1760856728
Name:IVORY, LATOYA RENEE (RSW)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:RENEE
Last Name:IVORY
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 HAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6642
Mailing Address - Country:US
Mailing Address - Phone:318-621-0910
Mailing Address - Fax:
Practice Address - Street 1:1111 HAWN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-621-0910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11895171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator