=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326059072
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD JOHN NORTHAM PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 11/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 923 16TH AVE S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-965-8788
-----------------------------------------------------
Fax | 208-965-2789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 923 16TH AVE S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-965-8788
-----------------------------------------------------
Fax | 208-965-2789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 406
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5698
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------