Provider Demographics
NPI:1376728022
Name:LABATAILLE, LORETTE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LORETTE
Middle Name:MARIE
Last Name:LABATAILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 7TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5297
Mailing Address - Country:US
Mailing Address - Phone:707-568-1101
Mailing Address - Fax:707-568-1103
Practice Address - Street 1:509 7TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5297
Practice Address - Country:US
Practice Address - Phone:707-568-1101
Practice Address - Fax:707-568-1103
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG240402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G240400Medicaid
CA00G240400Medicaid
00G240400Medicare PIN