=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033505763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAM NEWMON MA, LPCC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2015
-----------------------------------------------------
Last Update Date | 04/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320-H OSUNA RD NE SUITE 4
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-345-2778
-----------------------------------------------------
Fax | 505-345-2878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 647 CALLE DE BLAS
-----------------------------------------------------
City | CORRALES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87048-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. SAM NEWMON
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-350-3027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0171811
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------