Provider Demographics
NPI:1073262036
Name:NEW AGE CONSULTATION
Entity Type:Organization
Organization Name:NEW AGE CONSULTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IZAYAH
Authorized Official - Middle Name:T
Authorized Official - Last Name:NEWSOM
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:574-855-0009
Mailing Address - Street 1:1389 W MAPLE AVE APT C4
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1354
Mailing Address - Country:US
Mailing Address - Phone:574-855-0009
Mailing Address - Fax:
Practice Address - Street 1:1389 W MAPLE AVE APT C4
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1354
Practice Address - Country:US
Practice Address - Phone:574-855-0009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)