Provider Demographics
NPI:1801235692
Name:LATHAN, KIMBERLY R
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:LATHAN
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:PO BOX 151866
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89315-1212
Mailing Address - Country:US
Mailing Address - Phone:702-303-4286
Mailing Address - Fax:
Practice Address - Street 1:900 AVENUE O
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-2900
Practice Address - Country:US
Practice Address - Phone:702-303-4286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4696106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist