Provider Demographics
NPI:1174921753
Name:LATTIRE, BRETT (LAT, ATC)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:LATTIRE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8481 N EAST PRONG RD
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:IN
Mailing Address - Zip Code:47224-9733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8481 EAST PRONG ROAD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:IN
Practice Address - Zip Code:47224
Practice Address - Country:US
Practice Address - Phone:812-701-5946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002079A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer