Provider Demographics
NPI:1205305968
Name:LATORRACA, MICHAEL JAMES
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:LATORRACA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 S HAM LN STE A&B
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3530
Mailing Address - Country:US
Mailing Address - Phone:209-224-8940
Mailing Address - Fax:209-224-5076
Practice Address - Street 1:541 S HAM LN STE A&B
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3530
Practice Address - Country:US
Practice Address - Phone:224-894-0209
Practice Address - Fax:209-224-5076
Is Sole Proprietor?:No
Enumeration Date:2018-11-24
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200628346Medicaid