Provider Demographics
NPI:1891082046
Name:DALE, LATRICIA (LMT)
Entity type:Individual
Prefix:
First Name:LATRICIA
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 SEVEN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6708
Mailing Address - Country:US
Mailing Address - Phone:314-972-0409
Mailing Address - Fax:
Practice Address - Street 1:4130 SEVEN HILLS DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6708
Practice Address - Country:US
Practice Address - Phone:314-972-0409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005015259225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist