Healthcare Provider Details

I. General information

NPI: 1790476463
Provider Name (Legal Business Name): LATREACE HOPE LAACK MSW, APSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 NORTH AVE
CLEVELAND WI
53015-1413
US

IV. Provider business mailing address

625 E CLIFFORD ST
PLYMOUTH WI
53073-2311
US

V. Phone/Fax

Practice location:
  • Phone: 920-693-5600
  • Fax:
Mailing address:
  • Phone: 414-507-9037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number134214-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: