Provider Demographics
NPI:1225838360
Name:IKRAM, SAMAH (MA, LCAT, RDT)
Entity type:Individual
Prefix:
First Name:SAMAH
Middle Name:
Last Name:IKRAM
Suffix:
Gender:
Credentials:MA, LCAT, RDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 ROBERT AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-6543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1195 MARCELLA LN
Practice Address - Street 2:
Practice Address - City:WEST CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60185-5061
Practice Address - Country:US
Practice Address - Phone:510-499-4205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002588101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist