Healthcare Provider Details

I. General information

NPI: 1265674493
Provider Name (Legal Business Name): MS. LATONJA RENEE MCLEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 GROVE ST
GREENSBORO NC
27403-3410
US

IV. Provider business mailing address

1214 GROVE ST
GREENSBORO NC
27403-3410
US

V. Phone/Fax

Practice location:
  • Phone: 336-354-3886
  • Fax:
Mailing address:
  • Phone: 336-354-3886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24338
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA15130
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: