1104862333 NPI number — MRS. SHERRY ANN LATHAM PHD LPC

Table of content: MRS. SHERRY ANN LATHAM PHD LPC (NPI 1104862333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104862333 NPI number — MRS. SHERRY ANN LATHAM PHD LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATHAM
Provider First Name:
SHERRY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHD LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURKE
Provider Other First Name:
SHERRY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104862333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15276
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78212-8476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-212-8285
Provider Business Mailing Address Fax Number:
210-212-8229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1017 N MAIN AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78212-4723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-212-8285
Provider Business Practice Location Address Fax Number:
210-212-8229
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  01266 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 278850000 . This is a "MAGELLAN HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4190LC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 026240401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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