Provider Demographics
NPI:1053764407
Name:REID, LATIFAH TEYONNA (ATC, LAT)
Entity type:Individual
Prefix:
First Name:LATIFAH
Middle Name:TEYONNA
Last Name:REID
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 SANSOM ST
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-3405
Mailing Address - Country:US
Mailing Address - Phone:484-904-2001
Mailing Address - Fax:
Practice Address - Street 1:790 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4909
Practice Address - Country:US
Practice Address - Phone:630-296-2223
Practice Address - Fax:630-759-9510
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0064052255A2300X
DEJ3-00006642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer