Provider Demographics
NPI:1588107809
Name:NEWSON, LATRICE S
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:S
Last Name:NEWSON
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 1:10021 S WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2009
Mailing Address - Country:US
Mailing Address - Phone:312-882-7224
Mailing Address - Fax:
Practice Address - Street 1:3315 SPRING MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-8603
Practice Address - Country:US
Practice Address - Phone:702-754-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-19
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILXOH836546548OtherBLUE CROSS BLUE SHIELD