Healthcare Provider Details

I. General information

NPI: 1245487883
Provider Name (Legal Business Name): ANNIE LOUISE LATTUCA M.A. NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 S RURAL RD
TEMPE AZ
85282-3853
US

IV. Provider business mailing address

400 W IRONWOOD DR
CHANDLER AZ
85225-6649
US

V. Phone/Fax

Practice location:
  • Phone: 480-730-7100
  • Fax:
Mailing address:
  • Phone: 480-272-7892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4047832
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: