Provider Demographics
NPI:1013491315
Name:LATIMER, KELLY ANN (MSW STUDENT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:LATIMER
Suffix:
Gender:F
Credentials:MSW STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 BERCUT DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-0110
Mailing Address - Country:US
Mailing Address - Phone:916-441-3819
Mailing Address - Fax:916-441-6377
Practice Address - Street 1:630 BERCUT DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0110
Practice Address - Country:US
Practice Address - Phone:916-441-3819
Practice Address - Fax:916-441-6377
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program