Provider Demographics
NPI:1609335777
Name:BAHAM, MARJORIE NICOLE
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:NICOLE
Last Name:BAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N MORRISON BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2242
Mailing Address - Country:US
Mailing Address - Phone:985-551-5115
Mailing Address - Fax:
Practice Address - Street 1:1320 N MORRISON BLVD STE 105
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2242
Practice Address - Country:US
Practice Address - Phone:985-551-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1689020489Medicaid