Healthcare Provider Details

I. General information

NPI: 1700718111
Provider Name (Legal Business Name): LATITUDE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7807 ELM BIRCH LN
ROSHARON TX
77583-5603
US

IV. Provider business mailing address

7807 ELM BIRCH LN
ROSHARON TX
77583-5603
US

V. Phone/Fax

Practice location:
  • Phone: 713-469-0978
  • Fax:
Mailing address:
  • Phone: 713-469-0978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL GREEN
Title or Position: OWNER
Credential: LCSW
Phone: 513-227-6182