Basic Information
| Provider Information | |||||||||
| NPI: | 1659644367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LATTIS | ||||||||
| FirstName: | RANDY | ||||||||
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| Credential: | M.S., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 BANKS AVE | ||||||||
| Address2: | |||||||||
| City: | MCADOO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182372508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705901557 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 US-11 | ||||||||
| Address2: | |||||||||
| City: | SHAMOKIN DAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887264774 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2012 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-09-5277 | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1095277 | PA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.