Individual
LATHAN DEAN WISE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3400 STATE ST SITE G750, SALEM, MO 65560
(000) 000-0000
Mailing address
21600 OXNARD ST STE 1800, WOODLAND HILLS, CA 91367-7807
(818) 345-2345
(000) 000-0000
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
C056195007
MO
Other
Enumeration date
12/22/2020
Last updated
12/22/2020
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