Provider Demographics
NPI:1760692628
Name:LATIMORE, ROBERT ELLIOT (LMFT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELLIOT
Last Name:LATIMORE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S 12TH ST
Mailing Address - Street 2:BLDG A
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-2136
Mailing Address - Country:US
Mailing Address - Phone:408-568-4399
Mailing Address - Fax:408-971-6961
Practice Address - Street 1:124 S 12TH ST
Practice Address - Street 2:BLDG A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-2136
Practice Address - Country:US
Practice Address - Phone:408-568-4399
Practice Address - Fax:408-971-6961
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43259106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11759043OtherCAQH UNIVERSAL PROVIDER DATASOURCE