Provider Demographics
NPI:1902112055
Name:IHEME, MIRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:
Last Name:IHEME
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 IDLEWOOD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4827
Mailing Address - Country:US
Mailing Address - Phone:678-922-2834
Mailing Address - Fax:678-922-2270
Practice Address - Street 1:2227 IDLEWOOD RD STE 2
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4827
Practice Address - Country:US
Practice Address - Phone:678-922-2834
Practice Address - Fax:678-922-2270
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103TC1900X
GALPC002789101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling