Healthcare Provider Details

I. General information

NPI: 1508191628
Provider Name (Legal Business Name): LATITIA D BROWN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

5712 EUCLID AVE NE
ALBUQUERQUE NM
87110-4009
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-9633
  • Fax:
Mailing address:
  • Phone: 773-931-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0125311
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberT-0154431
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: