Provider Demographics
NPI:1316603053
Name:LATHAN, ANTHONY MICHELL (CADC-1/QMHP)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHELL
Last Name:LATHAN
Suffix:
Gender:M
Credentials:CADC-1/QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10763 SW GREENBURG RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5492
Mailing Address - Country:US
Mailing Address - Phone:503-684-8159
Mailing Address - Fax:
Practice Address - Street 1:10763 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5492
Practice Address - Country:US
Practice Address - Phone:503-684-8159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
OR24-07-11201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500813163Medicaid
OR500813165Medicaid