Provider Demographics
NPI:1043517089
Name:OLDHAM, SAMUEL DEWAYNE (PSYD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DEWAYNE
Last Name:OLDHAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W. D.L. INGRAM AVE, BLDG 1408
Mailing Address - Street 2:
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103
Mailing Address - Country:US
Mailing Address - Phone:575-904-3917
Mailing Address - Fax:
Practice Address - Street 1:224 W. D.L. INGRAM AVE, BLDG 1408
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:575-904-3917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical