Provider Demographics
NPI:1992474134
Name:ANDERSON, LATRICE DANIELLE
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:DANIELLE
Last Name:ANDERSON
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 1:1432 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-5137
Mailing Address - Country:US
Mailing Address - Phone:810-841-0708
Mailing Address - Fax:
Practice Address - Street 1:1432 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-5137
Practice Address - Country:US
Practice Address - Phone:810-841-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator