Provider Demographics
NPI:1477824530
Name:LATTY, ALICIA CAMILLE (MS)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:CAMILLE
Last Name:LATTY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 MANLY AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-4603
Mailing Address - Country:US
Mailing Address - Phone:772-766-4747
Mailing Address - Fax:
Practice Address - Street 1:2920 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5605
Practice Address - Country:US
Practice Address - Phone:772-766-4747
Practice Address - Fax:772-323-2404
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health