Provider Demographics
NPI:1629306956
Name:LATIMER, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:LATIMER
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 1:211 E SIX FORKS RD STE 218
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7755
Mailing Address - Country:US
Mailing Address - Phone:252-258-5176
Mailing Address - Fax:919-747-9172
Practice Address - Street 1:211 E SIX FORKS RD STE 218
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7755
Practice Address - Country:US
Practice Address - Phone:252-258-5176
Practice Address - Fax:919-747-9175
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NC1104808101YM0800X, 103TP2701X
NC1041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134177298Medicaid