Provider Demographics
NPI:1124259122
Name:LATHAN, QUEENIE V (LPCC-S)
Entity type:Individual
Prefix:MS
First Name:QUEENIE
Middle Name:V
Last Name:LATHAN
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 BRYAN PLACE, NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485
Mailing Address - Country:US
Mailing Address - Phone:330-219-5892
Mailing Address - Fax:
Practice Address - Street 1:165 E PARK AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2352
Practice Address - Country:US
Practice Address - Phone:330-544-8005
Practice Address - Fax:330-544-9379
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0700418SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional