Basic Information
| Provider Information | |||||||||
| NPI: | 1649338823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATHAM | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | ELISABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9536 PRINCETON SQUARE BLVD S APT 2507 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322568357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042344660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10250 NORMANDY BLVD UNIT 802 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322218064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043797155 | ||||||||
| FaxNumber: | 9043797165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 101YM0800X | MH8899 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 013943700 | 05 | FL | MEDICAID |