Provider Demographics
NPI:1649569575
Name:GASSOUMIS, ATHENA MARIE (MDIV, LADAC)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:MARIE
Last Name:GASSOUMIS
Suffix:
Gender:F
Credentials:MDIV, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115-119 COURT STREET
Mailing Address - Street 2:P.O.BOX 876
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801
Mailing Address - Country:US
Mailing Address - Phone:575-835-2389
Mailing Address - Fax:
Practice Address - Street 1:119 COURT ST
Practice Address - Street 2:POB 876
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4505
Practice Address - Country:US
Practice Address - Phone:575-835-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0087871101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)