Provider Demographics
NPI:1629552591
Name:LATIZ-HACKETT, ROLAND
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:
Last Name:LATIZ-HACKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 PARK AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2562
Mailing Address - Country:US
Mailing Address - Phone:732-494-0895
Mailing Address - Fax:
Practice Address - Street 1:3830 PARK AVE STE 202
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-2562
Practice Address - Country:US
Practice Address - Phone:732-494-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01822300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist