Provider Demographics
NPI:1720621527
Name:MCCLINE, LATREAVETTE LATISH
Entity type:Individual
Prefix:
First Name:LATREAVETTE
Middle Name:LATISH
Last Name:MCCLINE
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 1:213 E CASS ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-2812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 E CASS ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-2812
Practice Address - Country:US
Practice Address - Phone:630-551-8718
Practice Address - Fax:815-726-2708
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health