Provider Demographics
NPI:1366911489
Name:ANDERSON, LATOYA CHRISTINA
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:CHRISTINA
Last Name:ANDERSON
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 1:400 E GRAND AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-6200
Mailing Address - Country:US
Mailing Address - Phone:608-713-9291
Mailing Address - Fax:
Practice Address - Street 1:1818 PERSHING PL
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546
Practice Address - Country:US
Practice Address - Phone:608-312-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6671-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional