Provider Demographics
NPI:1467137950
Name:LATTIMORE, MARK THOMAS EDWARD (LMHCA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS EDWARD
Last Name:LATTIMORE
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:THOMAS EDWARD
Other - Last Name:LATTIMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCMHCA
Mailing Address - Street 1:191 WALKALOOSA WAY
Mailing Address - Street 2:
Mailing Address - City:MOORESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28114-7830
Mailing Address - Country:US
Mailing Address - Phone:828-289-9345
Mailing Address - Fax:
Practice Address - Street 1:143 OLD WAGY RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-9466
Practice Address - Country:US
Practice Address - Phone:828-245-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18865101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health