Provider Demographics
NPI:1790728541
Name:HAM, MARYANNA (EDD)
Entity Type:Individual
Prefix:
First Name:MARYANNA
Middle Name:
Last Name:HAM
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 THAYER HILL RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01098-9711
Mailing Address - Country:US
Mailing Address - Phone:413-238-0445
Mailing Address - Fax:
Practice Address - Street 1:50 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3909
Practice Address - Country:US
Practice Address - Phone:413-584-6855
Practice Address - Fax:413-585-1376
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2957103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03822Medicare ID - Type Unspecified