Provider Demographics
NPI:1255966388
Name:FARAUDO, LATASHA FAE
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:FAE
Last Name:FARAUDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATASHA
Other - Middle Name:FAE
Other - Last Name:MAKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:TASHA
Mailing Address - Street 1:3396 W 350 N
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:UT
Mailing Address - Zip Code:84015-7447
Mailing Address - Country:US
Mailing Address - Phone:801-643-6862
Mailing Address - Fax:
Practice Address - Street 1:6910 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3060
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT191464023106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician