Provider Demographics
NPI:1033719075
Name:ALLEN, LATERIA NICOLE (MED, LPC, NCC)
Entity type:Individual
Prefix:MRS
First Name:LATERIA
Middle Name:NICOLE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:MRS
Other - First Name:LATERIA
Other - Middle Name:NICOLE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M ED
Mailing Address - Street 1:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-0491
Mailing Address - Country:US
Mailing Address - Phone:229-269-6821
Mailing Address - Fax:
Practice Address - Street 1:2302 DAWSON ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707
Practice Address - Country:US
Practice Address - Phone:229-329-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014557101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health