Provider Demographics
NPI:1164973764
Name:LATHAM, ALYSSA RENEE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:RENEE
Last Name:LATHAM
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:MISS
Other - First Name:ALYSSA
Other - Middle Name:RENEE
Other - Last Name:MEUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13423 BLANCO RD # 635
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2187
Mailing Address - Country:US
Mailing Address - Phone:210-387-5721
Mailing Address - Fax:
Practice Address - Street 1:1511 ADOBE SPRINGS DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-4900
Practice Address - Country:US
Practice Address - Phone:817-818-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-16-23532103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1164973764OtherNPPES