Provider Demographics
NPI:1831285592
Name:LATHOS, VICTORIA ELLEN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ELLEN
Last Name:LATHOS
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 1:3415 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3371
Mailing Address - Country:US
Mailing Address - Phone:541-758-5900
Mailing Address - Fax:
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9695
Practice Address - Country:US
Practice Address - Phone:541-758-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2016-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37678106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist