Provider Demographics
NPI:1205246071
Name:LATHAM, CAROLYN (DPT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:LATHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KIENTZ LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2163
Mailing Address - Country:US
Mailing Address - Phone:615-604-5367
Mailing Address - Fax:415-492-1925
Practice Address - Street 1:14 KIENTZ LN
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2163
Practice Address - Country:US
Practice Address - Phone:615-604-5367
Practice Address - Fax:415-492-1925
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036762225100000X
CO00161192251X0800X
CAPT298393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY81-1375701OtherTIN