Healthcare Provider Details

I. General information

NPI: 1013491315
Provider Name (Legal Business Name): KELLY ANN LATIMER MSW STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 BERCUT DR
SACRAMENTO CA
95811-0110
US

IV. Provider business mailing address

630 BERCUT DR
SACRAMENTO CA
95811-0110
US

V. Phone/Fax

Practice location:
  • Phone: 916-441-3819
  • Fax: 916-441-6377
Mailing address:
  • Phone: 916-441-3819
  • Fax: 916-441-6377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: