Provider Demographics
NPI:1619403896
Name:STREET, LATORIA (BCAT)
Entity Type:Individual
Prefix:
First Name:LATORIA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:BCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 N TUSTIN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-7875
Mailing Address - Country:US
Mailing Address - Phone:855-581-0100
Mailing Address - Fax:949-709-0311
Practice Address - Street 1:14427 MERIDIAN PKWY
Practice Address - Street 2:#7E
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92518-3014
Practice Address - Country:US
Practice Address - Phone:855-581-0100
Practice Address - Fax:949-709-0311
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00001993106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician