Provider Demographics
NPI:1336747633
Name:MOOBERRY, LATRISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:LATRISHA
Middle Name:
Last Name:MOOBERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 E IDLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2891
Mailing Address - Country:US
Mailing Address - Phone:309-263-5565
Mailing Address - Fax:
Practice Address - Street 1:385 E IDLEWOOD ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2891
Practice Address - Country:US
Practice Address - Phone:309-270-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149022593104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364276135OtherTAX ID