Healthcare Provider Details

I. General information

NPI: 1649569575
Provider Name (Legal Business Name): ATHENA MARIE GASSOUMIS M.DIV., LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 COURT ST POB 876
SOCORRO NM
87801-4505
US

IV. Provider business mailing address

115-119 COURT STREET P.O.BOX 876
SOCORRO NM
87801
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-2389
  • Fax:
Mailing address:
  • Phone: 575-835-2389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0087871
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: