Provider Demographics
NPI:1861103277
Name:PEGRAM, LATOYA (LPAT, LPC, ART-BC)
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:LPAT, LPC, ART-BC
Other - Prefix:
Other - First Name:LATOYA
Other - Middle Name:
Other - Last Name:KINARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATR-BC
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NJ
Mailing Address - Zip Code:08065-0100
Mailing Address - Country:US
Mailing Address - Phone:856-209-3507
Mailing Address - Fax:
Practice Address - Street 1:103 OLD MARLTON PIKE STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8772
Practice Address - Country:US
Practice Address - Phone:856-223-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00904400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional