Provider Demographics
NPI:1225873284
Name:TAM, IDA (EDD, LMSW)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:
Last Name:TAM
Suffix:
Gender:F
Credentials:EDD, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 RUMSON RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5951
Mailing Address - Country:US
Mailing Address - Phone:917-453-4061
Mailing Address - Fax:
Practice Address - Street 1:715 OCEAN TER
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4542
Practice Address - Country:US
Practice Address - Phone:917-453-4061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YS0200X
NY069984104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool