Provider Demographics
NPI:1942021803
Name:LATTA, MATTHEW PAUL
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:LATTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 PRUITT HILL DR APT 415
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4633
Mailing Address - Country:US
Mailing Address - Phone:903-520-6420
Mailing Address - Fax:
Practice Address - Street 1:440 HIGHWAY 59 LOOP S STE 104
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-9011
Practice Address - Country:US
Practice Address - Phone:936-328-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123198235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist