Basic Information
| Provider Information | |||||||||
| NPI: | 1124259122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATHAN | ||||||||
| FirstName: | QUEENIE | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPCC-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1063 BRYAN PLACE, NW | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302195892 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 165 E PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444462352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305448005 | ||||||||
| FaxNumber: | 3305449379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E0700418SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.