Provider Demographics
NPI:1316295587
Name:GAITHER, LATRECE (MA)
Entity type:Individual
Prefix:
First Name:LATRECE
Middle Name:
Last Name:GAITHER
Suffix:
Gender:F
Credentials:MA
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 214
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-0214
Mailing Address - Country:US
Mailing Address - Phone:971-236-2728
Mailing Address - Fax:
Practice Address - Street 1:510 NE ROBERTS AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7484
Practice Address - Country:US
Practice Address - Phone:971-236-2728
Practice Address - Fax:855-719-2524
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5156101YM0800X
ORT1531106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist