Provider Demographics
NPI:1700552114
Name:LATTA, KERRILYNN J (LCSW)
Entity Type:Individual
Prefix:
First Name:KERRILYNN
Middle Name:J
Last Name:LATTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11225 N 28TH DR STE A-10214
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5606
Mailing Address - Country:US
Mailing Address - Phone:623-203-5151
Mailing Address - Fax:480-718-7487
Practice Address - Street 1:11225 N 28TH DR STE A-10214
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5606
Practice Address - Country:US
Practice Address - Phone:623-203-5151
Practice Address - Fax:480-718-7487
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-197341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical