Provider Demographics
NPI:1114552676
Name:SAM, MELISSA MARIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:SAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1612
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-1612
Mailing Address - Country:US
Mailing Address - Phone:505-486-4304
Mailing Address - Fax:
Practice Address - Street 1:CR 7165 RD 3 #14
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-8741
Practice Address - Country:US
Practice Address - Phone:505-486-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM505793579OtherDRIVERS LICENCE