Provider Demographics
NPI:1528064391
Name:LATHAM, DEBRA D (LCSW)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:D
Last Name:LATHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:D
Other - Last Name:LATHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2942 SIERRA CIR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7016
Mailing Address - Country:US
Mailing Address - Phone:325-949-0646
Mailing Address - Fax:325-942-7532
Practice Address - Street 1:3471 KNICKERBOCKER RD
Practice Address - Street 2:STE 508
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-8826
Practice Address - Country:US
Practice Address - Phone:325-942-7531
Practice Address - Fax:325-942-7532
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS067741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117983OtherSUPERIOR HEALTHPLAN
TX125054OtherMHN/HMC CLAIMS
TX80438WMedicare ID - Type Unspecified