Healthcare Provider Details

I. General information

NPI: 1386387413
Provider Name (Legal Business Name): BRODY LATHEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3833 N OAK STREET EXT
VALDOSTA GA
31605-1153
US

IV. Provider business mailing address

3833 N OAK STREET EXT
VALDOSTA GA
31605-1153
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-4815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: