Basic Information
| Provider Information | |||||||||
| NPI: | 1205917341 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LATIMER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513791718 | ||||||||
| FaxNumber: | 6513791738 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516284993 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12301SOCIALWORK | MN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 12301 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 856475200 | 05 | MN | MEDICAID |