MEDICARE: AZURE NEWMAN MHP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1447748074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZURE NEWMAN MHP

Provider Business Mailing Address
First Line	:	307 N 9TH ST
Second Line	:
City	:	ALTAMONT
State	:	IL
Zip	:	62411-1808
Country	:	US
Telephone Number	:	618-292-7801
Fax Number	:

Provider Business Practice Location Address
First Line	:	4110 N WATER TOWER PL
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6295
Country	:	US
Telephone Number	:	618-242-8266
Fax Number	:	618-242-1150

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2018
Last Update Date	:	04/30/2018

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