Healthcare Provider Details

I. General information

NPI: 1225838360
Provider Name (Legal Business Name): SAMAH IKRAM MA, LCAT, RDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 MARCELLA LN
WEST CHICAGO IL
60185-5061
US

IV. Provider business mailing address

787 ROBERT AVE
MADERA CA
93636-6543
US

V. Phone/Fax

Practice location:
  • Phone: 510-499-4205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number002588
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: