Healthcare Provider Details

I. General information

NPI: 1447610456
Provider Name (Legal Business Name): MICHELLE MARIE LATHON LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 BLUFF RD
MULLINS SC
29574-6020
US

IV. Provider business mailing address

3402 BLUFF RD
MULLINS SC
29574-6020
US

V. Phone/Fax

Practice location:
  • Phone: 667-352-5577
  • Fax:
Mailing address:
  • Phone: 667-352-5577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16849
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9750
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: