Provider Demographics
NPI:1356638340
Name:LATHAM, MASHEIL RENAY
Entity Type:Individual
Prefix:
First Name:MASHEIL
Middle Name:RENAY
Last Name:LATHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MASHEIL
Other - Middle Name:RENAY
Other - Last Name:MCCLENDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:48 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-1621
Mailing Address - Country:US
Mailing Address - Phone:856-343-9429
Mailing Address - Fax:
Practice Address - Street 1:48 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LINDENWOLD
Practice Address - State:NJ
Practice Address - Zip Code:08021-1621
Practice Address - Country:US
Practice Address - Phone:856-343-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ990367213101Y00000X, 101YA0400X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker