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General NPI Number Information
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NPI Number | 1760599211
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Entity Type | Individual
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Provider Name | TRACEY E LATZA PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 08/23/2006
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Last Update Date | 01/18/2022
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Provider Practice Location Address
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Address Line | 12760 W NORTH AVE BUILDING A
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City | BROOKFIELD
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State | WI
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Zip | 53005-4628
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Country | US
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Telephone | 262-439-5500
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Fax | 866-439-5221
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Provider Business Mailing Address
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Address Line | 12760 W NORTH AVE BUILDING A
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City | BROOKFIELD
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State | WI
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Zip | 53005-4628
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Country | US
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Telephone | 262-439-5500
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Fax | 866-439-5221
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 3601-125
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 3102-57
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License Number State | WI
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