Provider Demographics
NPI:1285493197
Name:LATORTUE, PHILANA JADE
Entity type:Individual
Prefix:
First Name:PHILANA
Middle Name:JADE
Last Name:LATORTUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 SE CARNIVAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2707
Mailing Address - Country:US
Mailing Address - Phone:772-348-1090
Mailing Address - Fax:
Practice Address - Street 1:2250 S JENKINS RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-5308
Practice Address - Country:US
Practice Address - Phone:772-462-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL363670028440106S00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst