Provider Demographics
NPI:1518970227
Name:HAM, AUDREY D (PHD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:D
Last Name:HAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 S LAKE AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3525
Mailing Address - Country:US
Mailing Address - Phone:626-319-6327
Mailing Address - Fax:
Practice Address - Street 1:380 SOUTH LAKE
Practice Address - Street 2:SUITE 205
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101
Practice Address - Country:US
Practice Address - Phone:626-319-6327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22723103T00000X
HIPSY -953103TC0700X
NY016612-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical