MEDICARE: LATONYA GRANT LCAS, MAC, CSAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	0710102076	VA

General Provider Information

NPI Number	:	1346088275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATONYA GRANT LCAS, MAC, CSAC

Provider Business Mailing Address
First Line	:	11324 WINGET POND RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-7205
Country	:	US
Telephone Number	:	757-705-5025
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 US HIGHWAY 64 E
Second Line	:
City	:	PLYMOUTH
State	:	NC
Zip	:	27962-2200
Country	:	US
Telephone Number	:	757-705-5025
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2024
Last Update Date	:	05/23/2026

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