Provider Demographics
NPI:1467180224
Name:NEWNOM, SUSAN (CADC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NEWNOM
Suffix:
Gender:F
Credentials:CADC
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 2036
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-8036
Mailing Address - Country:US
Mailing Address - Phone:732-367-4700
Mailing Address - Fax:
Practice Address - Street 1:848 W BAY AVE
Practice Address - Street 2:
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005-2126
Practice Address - Country:US
Practice Address - Phone:609-660-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37CA00139700106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid