Provider Demographics
NPI:1881879534
Name:LATHAM, MALLIE FERNACIA
Entity type:Individual
Prefix:
First Name:MALLIE
Middle Name:FERNACIA
Last Name:LATHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5052
Mailing Address - Country:US
Mailing Address - Phone:415-928-7800
Mailing Address - Fax:415-928-3710
Practice Address - Street 1:325 OHIO ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5052
Practice Address - Country:US
Practice Address - Phone:415-928-7800
Practice Address - Fax:415-928-3710
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)