Healthcare Provider Details

I. General information

NPI: 1861103277
Provider Name (Legal Business Name): LATOYA PEGRAM LPAT, LPC, ART-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LATOYA KINARD ATR-BC

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 OLD MARLTON PIKE STE 101
MEDFORD NJ
08055-8772
US

IV. Provider business mailing address

PO BOX 100
PALMYRA NJ
08065-0100
US

V. Phone/Fax

Practice location:
  • Phone: 856-223-2222
  • Fax:
Mailing address:
  • Phone: 856-209-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00904400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: