Provider Demographics
NPI:1275191306
Name:LATHAM, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LATHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2311
Mailing Address - Country:US
Mailing Address - Phone:734-439-2922
Mailing Address - Fax:
Practice Address - Street 1:410 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2311
Practice Address - Country:US
Practice Address - Phone:734-439-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.00277431041C0700X
MI68020736031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802073603OtherSOCIAL WORK LICENSE THROUGH MICHIGAN DEPARTMENT OF CONSUMER & INDUSTRY SERVICES