Healthcare Provider Details

I. General information

NPI: 1205309721
Provider Name (Legal Business Name): CHARLES J LATORRE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 ANGELS PATH
DE PERE WI
54115-4050
US

IV. Provider business mailing address

PO BOX 22040
GREEN BAY WI
54305-2040
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-2855
  • Fax: 920-338-9270
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6831-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: