Provider Demographics
NPI:1053729145
Name:ELMORE, LOUCRECIA
Entity type:Individual
Prefix:
First Name:LOUCRECIA
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11706 BRIGHTON KNOLL LOOP
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2147
Mailing Address - Country:US
Mailing Address - Phone:813-318-2163
Mailing Address - Fax:
Practice Address - Street 1:8526 CATALINA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1700
Practice Address - Country:US
Practice Address - Phone:813-690-1016
Practice Address - Fax:813-602-0157
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW229421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020014600Medicaid