Provider Demographics
NPI:1497962484
Name:LATTIMORE, VERGEL L III (PHD)
Entity Type:Individual
Prefix:DR
First Name:VERGEL
Middle Name:L
Last Name:LATTIMORE
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 COLUMBUS PIKE
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-3211
Mailing Address - Country:US
Mailing Address - Phone:740-362-3137
Mailing Address - Fax:740-362-3381
Practice Address - Street 1:3081 COLUMBUS PIKE
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-3211
Practice Address - Country:US
Practice Address - Phone:740-362-3137
Practice Address - Fax:740-362-3381
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF099106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist