Provider Demographics
NPI:1629196712
Name:LATU, ELIZABETH HOPE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:HOPE
Last Name:LATU
Suffix:
Gender:F
Credentials:PSYD
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5361
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:8312 KASEMAN CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7639
Practice Address - Country:US
Practice Address - Phone:505-291-5300
Practice Address - Fax:505-291-5301
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21810103T00000X
NM1386103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26722224Medicaid
NM26722224Medicaid