=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336483122
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY DENISE - LATTEN DAVIDSON MFTT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2012
-----------------------------------------------------
Last Update Date | 08/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4073-75 WEST PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-733-0471
-----------------------------------------------------
Fax | 323-733-6427
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6820 LA TIJERA BLVD STE 208
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-864-7788
-----------------------------------------------------
Fax | 323-733-6427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT108954
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------