Healthcare Provider Details

I. General information

NPI: 1962581082
Provider Name (Legal Business Name): DEBORAH LATZKE MS, LPCC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 ELMWOOD AVE S
LE SUEUR MN
56058-2169
US

IV. Provider business mailing address

29150 441ST AVE
GAYLORD MN
55334-2202
US

V. Phone/Fax

Practice location:
  • Phone: 507-931-8040
  • Fax: 507-931-8060
Mailing address:
  • Phone: 218-790-2165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301854
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC00107
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: