Provider Demographics
NPI:1750030557
Name:NEWSOM, NELLIE (CADC, CSAC)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:
Last Name:NEWSOM
Suffix:
Gender:F
Credentials:CADC, CSAC
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 1342
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-1342
Mailing Address - Country:US
Mailing Address - Phone:252-365-0182
Mailing Address - Fax:
Practice Address - Street 1:1519 PATSY ALBRITTON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4909
Practice Address - Country:US
Practice Address - Phone:252-365-1803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3126101YA0400X
NC1579101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)