Provider Demographics
NPI:1659644367
Name:LATTIS, RANDY (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:LATTIS
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BANKS AVE
Mailing Address - Street 2:
Mailing Address - City:MCADOO
Mailing Address - State:PA
Mailing Address - Zip Code:18237-2508
Mailing Address - Country:US
Mailing Address - Phone:570-590-1557
Mailing Address - Fax:
Practice Address - Street 1:45 US-11
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876
Practice Address - Country:US
Practice Address - Phone:888-726-4774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-09-5277103K00000X
PA1095277103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst