Provider Demographics
NPI:1013378470
Name:OLDERHAM, JIM (LPCC, CDCA)
Entity Type:Individual
Prefix:MR
First Name:JIM
Middle Name:
Last Name:OLDERHAM
Suffix:
Gender:M
Credentials:LPCC, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-1305
Mailing Address - Country:US
Mailing Address - Phone:937-661-1682
Mailing Address - Fax:
Practice Address - Street 1:325 S ELM ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-1305
Practice Address - Country:US
Practice Address - Phone:937-661-1682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1500082101YM0800X
OHE1901459101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH292528Medicaid