Healthcare Provider Details

I. General information

NPI: 1356065502
Provider Name (Legal Business Name): LATRECE GAITHER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 NE ROBERTS AVE STE 200
GRESHAM OR
97030-7484
US

IV. Provider business mailing address

PO BOX 214
FAIRVIEW OR
97024-0214
US

V. Phone/Fax

Practice location:
  • Phone: 971-236-2728
  • Fax: 855-719-2524
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1316295587
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNPI

VIII. Authorized Official

Name: LATRECE GAITHER
Title or Position: OWNER/PROVIDER
Credential:
Phone: 971-236-2728