Basic Information
| Provider Information | |||||||||
| NPI: | 1447975818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LATITUDE PSYCHIATRY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 BELMONT AVE | ||||||||
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| City: | WEST SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010891954 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 39 NEW LONDON TPKE STE 230B | ||||||||
| Address2: | |||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060332061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605772692 | ||||||||
| FaxNumber: | 8609731847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2022 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRAZIANO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4134334712 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.