Provider Demographics
NPI:1225138209
Name:LATTAVO, CYNTHIA (MFT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:LATTAVO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 894089
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-4089
Mailing Address - Country:US
Mailing Address - Phone:951-440-9272
Mailing Address - Fax:951-694-4030
Practice Address - Street 1:39755 MURRIETA HOT SPRINGS RD
Practice Address - Street 2:BUILDING D - 160
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-9101
Practice Address - Country:US
Practice Address - Phone:951-440-9272
Practice Address - Fax:951-694-4030
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37426106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT374260OtherBLUESHIELD OF CA
CA0000033BGCSMedicaid