Provider Demographics
NPI:1326059072
Name:NORTHAM, EDWARD JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:NORTHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4731
Mailing Address - Country:US
Mailing Address - Phone:208-965-8788
Mailing Address - Fax:208-965-2789
Practice Address - Street 1:923 16TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4731
Practice Address - Country:US
Practice Address - Phone:208-965-8788
Practice Address - Fax:208-965-2789
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE406101YM0800X
ID5698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE91185390827Medicaid
NE345988000OtherMAGELLAN
NE114961OtherVALUE OPTIONS
NE84913OtherBLUE CROSS BLUE SHIELD
NE91185390826Medicaid
NE91185390827Medicaid