Provider Demographics
NPI:1669684619
Name:LATTA, KATHLEEN MARIE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:LATTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 MEGAN CT
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-9812
Mailing Address - Country:US
Mailing Address - Phone:815-521-0958
Mailing Address - Fax:
Practice Address - Street 1:2423 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5483
Practice Address - Country:US
Practice Address - Phone:815-725-9992
Practice Address - Fax:815-725-9993
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILKL84520906P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist