Provider Demographics
NPI:1770334245
Name:LATHAM, DARITTA MARIE
Entity type:Individual
Prefix:
First Name:DARITTA
Middle Name:MARIE
Last Name:LATHAM
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 1:30799 PINETREE RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5903
Mailing Address - Country:US
Mailing Address - Phone:440-657-0556
Mailing Address - Fax:216-274-9696
Practice Address - Street 1:8121 GRAND DIVISION AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-1246
Practice Address - Country:US
Practice Address - Phone:440-657-0556
Practice Address - Fax:216-274-9696
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health