Provider Demographics
NPI:1376055483
Name:LATHERS, LARAVAN MICHELLE
Entity Type:Individual
Prefix:
First Name:LARAVAN
Middle Name:MICHELLE
Last Name:LATHERS
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 1:19265 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:70462-7021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19265 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:LA
Practice Address - Zip Code:70462-7021
Practice Address - Country:US
Practice Address - Phone:985-517-5773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health