Provider Demographics
NPI:1770244741
Name:HARLEY, LATAVIA JO NEKOL
Entity Type:Individual
Prefix:
First Name:LATAVIA JO
Middle Name:NEKOL
Last Name:HARLEY
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 1:1430 OLIVE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2303
Mailing Address - Country:US
Mailing Address - Phone:314-206-3700
Mailing Address - Fax:
Practice Address - Street 1:1150 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8077
Practice Address - Country:US
Practice Address - Phone:314-308-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IL178.018456101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)