Provider Demographics
NPI:1962033126
Name:NEWSOM, VICKY A
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:A
Last Name:NEWSOM
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 1:6292 W LINDA LN
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-5847
Mailing Address - Country:US
Mailing Address - Phone:480-540-2058
Mailing Address - Fax:
Practice Address - Street 1:6292 W LINDA LN
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-5847
Practice Address - Country:US
Practice Address - Phone:480-540-2058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1339101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional