Healthcare Provider Details

I. General information

NPI: 1215429071
Provider Name (Legal Business Name): VICTORIA LATINI LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 TATUM ST
WOODBURY NJ
08096-3499
US

IV. Provider business mailing address

404 TATUM ST
WOODBURY NJ
08096-3499
US

V. Phone/Fax

Practice location:
  • Phone: 856-845-8050
  • Fax:
Mailing address:
  • Phone: 856-845-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00356200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: