Provider Demographics
NPI:1083380984
Name:LATHAM, SUMMERSLEE MADISON
Entity Type:Individual
Prefix:
First Name:SUMMERSLEE
Middle Name:MADISON
Last Name:LATHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12970 E CIBOLA RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-3563
Mailing Address - Country:US
Mailing Address - Phone:702-596-0078
Mailing Address - Fax:
Practice Address - Street 1:10613 N HAYDEN RD STE J-103
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5683
Practice Address - Country:US
Practice Address - Phone:480-485-8824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health