Individual
MELISSA MARIE SAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
CR 7165 RD 3 #14, BLOOMFIELD, NM 87413-8741
(505) 486-4304
Mailing address
PO BOX 1612, BLOOMFIELD, NM 87413-1612
(505) 486-4304
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
505793579
DRIVERS LICENCE
NM
Enumeration date
03/05/2020
Last updated
03/05/2020
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