Provider Demographics
NPI:1497274781
Name:LATHAM, SHANE GREGORY
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:GREGORY
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 1:335 ARABIAN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:AL
Mailing Address - Zip Code:35051-3262
Mailing Address - Country:US
Mailing Address - Phone:815-353-1013
Mailing Address - Fax:
Practice Address - Street 1:100 CENTURY PARK S STE 102
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35226-3922
Practice Address - Country:US
Practice Address - Phone:888-386-9624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6552101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional