Provider Demographics
NPI:1689133076
Name:LATTICE EDUCATIONAL SERVICES
Entity Type:Organization
Organization Name:LATTICE EDUCATIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-571-1234
Mailing Address - Street 1:3273 AIRWAY DR STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2080
Mailing Address - Country:US
Mailing Address - Phone:707-571-1234
Mailing Address - Fax:
Practice Address - Street 1:3273 AIRWAY DR STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2080
Practice Address - Country:US
Practice Address - Phone:707-571-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty