Healthcare Provider Details

I. General information

NPI: 1043473002
Provider Name (Legal Business Name): OCTAVIANA IMELDA PRIMA HEMMY ASAMSAMA PSYD, DRPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 ERIE AVE
CINCINNATI OH
45208-1982
US

IV. Provider business mailing address

3665 ERIE AVE
CINCINNATI OH
45208-1982
US

V. Phone/Fax

Practice location:
  • Phone: 513-273-0450
  • Fax:
Mailing address:
  • Phone: 513-273-0450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number05499
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP.07904
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: