Provider Demographics
NPI:1821196270
Name:LOVE, LETONYA
Entity Type:Individual
Prefix:
First Name:LETONYA
Middle Name:
Last Name:LOVE
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 1:1415 W NC HIGHWAY 54
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5577
Mailing Address - Country:US
Mailing Address - Phone:919-402-0120
Mailing Address - Fax:
Practice Address - Street 1:5720 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-9089
Practice Address - Country:US
Practice Address - Phone:919-484-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2499103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107258Medicaid