Provider Demographics
NPI:1255923702
Name:TEAGUE-HARVEY, LATORIS
Entity type:Individual
Prefix:
First Name:LATORIS
Middle Name:
Last Name:TEAGUE-HARVEY
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 1:107 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-2323
Mailing Address - Country:US
Mailing Address - Phone:334-796-4834
Mailing Address - Fax:
Practice Address - Street 1:1733 W MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1345
Practice Address - Country:US
Practice Address - Phone:334-347-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician