Provider Demographics
NPI:1871794917
Name:MOORE, LATONYA RAYETTE (LCSW)
Entity type:Individual
Prefix:MS
First Name:LATONYA
Middle Name:RAYETTE
Last Name:MOORE
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 1:18103 WOODINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2560
Mailing Address - Country:US
Mailing Address - Phone:980-365-9933
Mailing Address - Fax:
Practice Address - Street 1:18103 WOODINGHAM DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2560
Practice Address - Country:US
Practice Address - Phone:980-365-9933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0048491041C0700X
DCLC3029771041C0700X
MD106011041C0700X
VA09040105401041C0700X
MI68011175671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106306Medicaid