Provider Demographics
NPI:1891060679
Name:HART, LATARA (LOTR, MOT, CDP, ISTM)
Entity type:Individual
Prefix:
First Name:LATARA
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:LOTR, MOT, CDP, ISTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 541885
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-1885
Mailing Address - Country:US
Mailing Address - Phone:469-580-9733
Mailing Address - Fax:214-988-1542
Practice Address - Street 1:2993 S STATE HIGHWAY 360 STE 200
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8906
Practice Address - Country:US
Practice Address - Phone:817-618-5550
Practice Address - Fax:214-988-1542
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118175225XG0600X, 225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX404282201Medicaid