Healthcare Provider Details

I. General information

NPI: 1790371680
Provider Name (Legal Business Name): ELIZABETH CHAUVIN LATIOLAIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555-1120
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265-1120
US

V. Phone/Fax

Practice location:
  • Phone: 409-772-2166
  • Fax: 409-772-2663
Mailing address:
  • Phone: 409-772-2222
  • Fax: 409-772-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number36460
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: