Provider Demographics
NPI:1528264488
Name:LATUSECK, DOUGLAS J (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:LATUSECK
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1006
Mailing Address - Country:US
Mailing Address - Phone:651-717-6549
Mailing Address - Fax:651-717-6697
Practice Address - Street 1:7525 4TH AVE
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1006
Practice Address - Country:US
Practice Address - Phone:651-717-6549
Practice Address - Fax:651-717-6697
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4822103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical