Basic Information
| Provider Information | |||||||||
| NPI: | 1629601554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALTHON | ||||||||
| FirstName: | LADIVA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | MA, LLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALTHON | ||||||||
| OtherFirstName: | LA'DIVA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MA, LLPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486206400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 32961 MIDDLEBELT RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483341729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488551540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401018018 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6401018018 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.