Provider Demographics
NPI:1073923298
Name:LATESSA, EMILY KATHERINE (EDS)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:KATHERINE
Last Name:LATESSA
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:KATHERINE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:6451 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4109
Mailing Address - Country:US
Mailing Address - Phone:440-974-5241
Mailing Address - Fax:
Practice Address - Street 1:6451 CENTER ST
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4109
Practice Address - Country:US
Practice Address - Phone:440-974-5241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3151572103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool