Provider Demographics
NPI:1649338823
Name:LATHAM, AUDRA ELISABETH (LMHC)
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:ELISABETH
Last Name:LATHAM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9536 PRINCETON SQUARE BLVD S APT 2507
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8357
Mailing Address - Country:US
Mailing Address - Phone:904-234-4660
Mailing Address - Fax:
Practice Address - Street 1:10250 NORMANDY BLVD UNIT 802
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-8064
Practice Address - Country:US
Practice Address - Phone:904-379-7155
Practice Address - Fax:904-379-7165
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8899101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013943700Medicaid