Provider Demographics
NPI:1427289560
Name:ISHAM, STEVEN RAY (MA, LBSW)
Entity type:Individual
Prefix:PROF
First Name:STEVEN
Middle Name:RAY
Last Name:ISHAM
Suffix:
Gender:M
Credentials:MA, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 N 112TH LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5849
Mailing Address - Country:US
Mailing Address - Phone:623-907-2828
Mailing Address - Fax:
Practice Address - Street 1:2402 N 112TH LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5849
Practice Address - Country:US
Practice Address - Phone:623-907-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
AZLBSW-1365104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst