Healthcare Provider Details

I. General information

NPI: 1902112055
Provider Name (Legal Business Name): MIRA IHEME PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 IDLEWOOD RD STE 2
TUCKER GA
30084-4827
US

IV. Provider business mailing address

2227 IDLEWOOD RD STE 2
TUCKER GA
30084-4827
US

V. Phone/Fax

Practice location:
  • Phone: 678-922-2834
  • Fax: 678-922-2270
Mailing address:
  • Phone: 678-922-2834
  • Fax: 678-922-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC002789
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: