Provider Demographics
NPI:1356065502
Name:LATRECE GAITHER, LLC
Entity type:Organization
Organization Name:LATRECE GAITHER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LATRECE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAITHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-236-2728
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-0214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 NE ROBERTS AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7484
Practice Address - Country:US
Practice Address - Phone:971-236-2728
Practice Address - Fax:855-719-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1316295587OtherNPI