Provider Demographics
NPI:1699214601
Name:LATKA, LACEY RAE (LMFT)
Entity type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:RAE
Last Name:LATKA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BRIDGEGATE ST
Mailing Address - Street 2:#108
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1448
Mailing Address - Country:US
Mailing Address - Phone:805-601-7044
Mailing Address - Fax:
Practice Address - Street 1:1800 BRIDGEGATE ST
Practice Address - Street 2:#108
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-1448
Practice Address - Country:US
Practice Address - Phone:805-601-7044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97122106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist