Healthcare Provider Details

I. General information

NPI: 1285585091
Provider Name (Legal Business Name): LATANYA R LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2026
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21250 BOX SPRINGS RD STE 104
MORENO VALLEY CA
92557-8707
US

IV. Provider business mailing address

21250 BOX SPRINGS RD STE 106
MORENO VALLEY CA
92557-8707
US

V. Phone/Fax

Practice location:
  • Phone: 951-369-8036
  • Fax: 951-369-8036
Mailing address:
  • Phone: 951-369-8036
  • Fax: 951-369-8036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW130029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: