Provider Demographics
NPI:1760599211
Name:LATZA, TRACEY E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:E
Last Name:LATZA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12760 W NORTH AVE
Mailing Address - Street 2:BUILDING A
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4628
Mailing Address - Country:US
Mailing Address - Phone:262-439-5500
Mailing Address - Fax:866-439-5221
Practice Address - Street 1:12760 W NORTH AVE
Practice Address - Street 2:BUILDING A
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4628
Practice Address - Country:US
Practice Address - Phone:262-439-5500
Practice Address - Fax:866-439-5221
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3601-125101Y00000X
WI3102-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor