Provider Demographics
NPI:1437505187
Name:HAM, IDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:HAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 FAYETTEVILLE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7082
Mailing Address - Country:US
Mailing Address - Phone:919-544-3907
Mailing Address - Fax:
Practice Address - Street 1:6815 FAYETTEVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7082
Practice Address - Country:US
Practice Address - Phone:919-544-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22527101YA0400X
NC741911101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool