MEDICARE: DR. MARION STEVENS LATHAM PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1310	GA

General Provider Information

NPI Number	:	1538244678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARION STEVENS LATHAM PH.D

Provider Business Mailing Address
First Line	:	2801 BUFORD HWY NE
Second Line	:	550B
City	:	ATLANTA
State	:	GA
Zip	:	30329-2149
Country	:	US
Telephone Number	:	404-636-9402
Fax Number	:	404-636-9592

Provider Business Practice Location Address
First Line	:	2801 BUFORD HWY NE
Second Line	:	550B
City	:	ATLANTA
State	:	GA
Zip	:	30329-2149
Country	:	US
Telephone Number	:	404-636-9402
Fax Number	:	404-636-9592

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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