Provider Demographics
NPI:1316603053
Name:LATHAN, ANTHONY MICHELL (CADC-R/QMHP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHELL
Last Name:LATHAN
Suffix:
Gender:M
Credentials:CADC-R/QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:1310 SW 17TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-2522
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-467-4077
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
ORT-21-1167101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500813163Medicaid
OR500813165Medicaid