Provider Demographics
NPI:1700189370
Name:GASTON, LATINA R (MA)
Entity Type:Individual
Prefix:
First Name:LATINA
Middle Name:R
Last Name:GASTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13655 RIVERPORT DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-4812
Mailing Address - Country:US
Mailing Address - Phone:800-548-6549
Mailing Address - Fax:
Practice Address - Street 1:13655 RIVERPORT DR
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-4812
Practice Address - Country:US
Practice Address - Phone:800-548-6549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011033849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional