MEDICARE: MISS LATRECIA LATICE FORD LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	75816	TX

General Provider Information

NPI Number	:	1477022689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LATRECIA LATICE FORD LPC

Provider Business Mailing Address
First Line	:	4211 WHITNEY GRN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78244-1682
Country	:	US
Telephone Number	:	210-781-5831
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 WHITNEY GREEN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78244-7824
Country	:	US
Telephone Number	:	210-781-5831
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2018
Last Update Date	:	11/16/2018

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