MEDICARE: DR. DOUGLAS J LATUSECK PSYD, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP4822	MN

General Provider Information

NPI Number	:	1528264488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS J LATUSECK PSYD, LP

Provider Business Mailing Address
First Line	:	7525 4TH AVE
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1006
Country	:	US
Telephone Number	:	651-717-6549
Fax Number	:	651-717-6697

Provider Business Practice Location Address
First Line	:	7525 4TH AVE
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1006
Country	:	US
Telephone Number	:	651-717-6549
Fax Number	:	651-717-6697

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	11/28/2007

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