Provider Demographics
NPI:1962626994
Name:LATIMER-SPORT, MAISHA (BA)
Entity Type:Individual
Prefix:MISS
First Name:MAISHA
Middle Name:
Last Name:LATIMER-SPORT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CIRCLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905
Mailing Address - Country:US
Mailing Address - Phone:781-595-2413
Mailing Address - Fax:781-598-0210
Practice Address - Street 1:11 CIRCLE AVENUE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905
Practice Address - Country:US
Practice Address - Phone:781-595-2413
Practice Address - Fax:781-598-0210
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator