MEDICARE: MS. LATREL DORTCH

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	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1619825783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATREL DORTCH

Provider Business Mailing Address
First Line	:	114 BROUGHTON AVE
Second Line	:
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-3989
Country	:	US
Telephone Number	:	973-932-0178
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 BROUGHTON AVE
Second Line	:
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-3989
Country	:	US
Telephone Number	:	973-932-0178
Fax Number	:

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

Provider Enumeration Date	:	03/17/2026
Last Update Date	:	03/17/2026

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