Provider Demographics
NPI:1801913181
Name:LATAWIEC, TAMARA (PSYD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LATAWIEC
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 W FRONT ST STE 18
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1600
Mailing Address - Country:US
Mailing Address - Phone:732-720-3236
Mailing Address - Fax:
Practice Address - Street 1:43 W FRONT ST STE 18
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1600
Practice Address - Country:US
Practice Address - Phone:732-720-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4894103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
235420OtherMEDICARE PTAN