Basic Information
| Provider Information | |||||||||
| NPI: | 1003002684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATT | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454041815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376415072 | ||||||||
| FaxNumber: | 9376416129 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 VALLEY ST | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454042070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376413401 | ||||||||
| FaxNumber: | 9376413046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1501349-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0185897 | 05 | OH | MEDICAID |