MEDICARE: MRS. SUSAN B MOSSMAN MA

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	0169	NM

General Provider Information

NPI Number	:	1619080421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN B MOSSMAN MA

Provider Business Mailing Address
First Line	:	920 5TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4332
Country	:	US
Telephone Number	:	505-425-2707
Fax Number	:	505-425-3324

Provider Business Practice Location Address
First Line	:	920 5TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4332
Country	:	US
Telephone Number	:	505-425-2707
Fax Number	:	505-425-3324

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	07/08/2007

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