Provider Demographics
NPI:1215389317
Name:LATAILLE, JOHN (LMSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LATAILLE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16101 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3902
Mailing Address - Country:US
Mailing Address - Phone:718-262-8190
Mailing Address - Fax:718-943-7484
Practice Address - Street 1:16101 89TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3902
Practice Address - Country:US
Practice Address - Phone:718-262-8190
Practice Address - Fax:718-943-7484
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097677104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker