Provider Demographics
NPI:1245487883
Name:LATTUCA, ANNIE LOUISE (MA NCSP)
Entity type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:LOUISE
Last Name:LATTUCA
Suffix:
Gender:F
Credentials:MA NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-6649
Mailing Address - Country:US
Mailing Address - Phone:480-272-7892
Mailing Address - Fax:
Practice Address - Street 1:3205 S RURAL RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-3853
Practice Address - Country:US
Practice Address - Phone:480-730-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4047832103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool