Provider Demographics
NPI:1851439988
Name:LATHAM, EDWARD E JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:E
Last Name:LATHAM
Suffix:JR
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 1:404 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4828
Mailing Address - Country:US
Mailing Address - Phone:423-392-6898
Mailing Address - Fax:423-392-6900
Practice Address - Street 1:404 E MARKET ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4828
Practice Address - Country:US
Practice Address - Phone:423-392-6898
Practice Address - Fax:423-392-6900
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1405103TA0400X, 103TA0700X, 103TC0700X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN132696OtherVALUE OPTIONS
TN1437005OtherUMWA
TN063454OtherBCBS VA
TN0099539OtherBCBSTN
TN6109533OtherUNITED HEALTHCARE
TN9213176OtherPHCS
TN241583000OtherMAGELLAN
TN4418397OtherAETNA
TN4067035OtherBCBSTN-MEDICAL
TN4418397OtherAETNA
TN3582590Medicare ID - Type Unspecified