Provider Demographics
NPI:1770646572
Name:LATHAM, KELMIRA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELMIRA
Middle Name:
Last Name:LATHAM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 SOUTHAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7671
Mailing Address - Country:US
Mailing Address - Phone:252-717-6769
Mailing Address - Fax:252-756-4614
Practice Address - Street 1:3906 SOUTHAMPTON CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7671
Practice Address - Country:US
Practice Address - Phone:252-717-6769
Practice Address - Fax:252-756-4614
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6412235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412433Medicaid