Provider Demographics
NPI:1255741781
Name:DURHAM, ALICIA M (MFTA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:DURHAM
Suffix:
Gender:F
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 RIVEROAKS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2031
Mailing Address - Country:US
Mailing Address - Phone:502-322-6456
Mailing Address - Fax:
Practice Address - Street 1:3900 RIVEROAKS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241
Practice Address - Country:US
Practice Address - Phone:502-322-6456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2012-004106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist