Basic Information
| Provider Information | |||||||||
| NPI: | 1467400903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATELLA | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | NALL | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 DAWN LN | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456909695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409477783 | ||||||||
| FaxNumber: | 7409474226 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 DAWN LN | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456909695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409477783 | ||||||||
| FaxNumber: | 7409474226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 12/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E-0002375 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 000000305801 | 01 | OH | ANTHEM | OTHER |