Provider Demographics
NPI:1720335540
Name:EASTHAM, TAMMY ANN (ED S)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:ANN
Last Name:EASTHAM
Suffix:
Gender:F
Credentials:ED S
Other - Prefix:MISS
Other - First Name:TAMMY
Other - Middle Name:ANN
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-0683
Mailing Address - Country:US
Mailing Address - Phone:208-550-7559
Mailing Address - Fax:
Practice Address - Street 1:200 CENTER ST
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035
Practice Address - Country:US
Practice Address - Phone:505-832-4421
Practice Address - Fax:505-832-4472
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12004920103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool