Provider Demographics
NPI:1528417672
Name:LATINO-DAVIS, DESARAE (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:DESARAE
Middle Name:
Last Name:LATINO-DAVIS
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PARTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4323
Mailing Address - Country:US
Mailing Address - Phone:860-445-5220
Mailing Address - Fax:
Practice Address - Street 1:10 PARTRIDGE RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4323
Practice Address - Country:US
Practice Address - Phone:860-445-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer