MEDICARE: STATE OF NEVADA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1013099944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF NEVADA

Provider Business Mailing Address
First Line	:	ATTN: CYNDI SMITH
Second Line	:	240 S. HUMAHUACA
City	:	PAHRUMP
State	:	NV
Zip	:	89048-2199
Country	:	US
Telephone Number	:	775-751-7406
Fax Number	:	775-751-7409

Provider Business Practice Location Address
First Line	:	415 US HIGHWAY 95A S BLDG 1
Second Line	:
City	:	FERNLEY
State	:	NV
Zip	:	89408-9261
Country	:	US
Telephone Number	:	775-575-7744
Fax Number	:	775-575-7769

Authorized Official
Title or Position	:	AGENCY MANAGER
Name	:	ELLEN RICHARDSON-ADAMS
Credential	:
Telephone Number	:	775-486-4400

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	11/10/2022

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Practice Location Address:

415 US HIGHWAY 95A S UNIT A
FERNLEY, NV
89408-9261

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Practice Fax: 775-575-5702

1760542021 — DARREN M ANDERSON LCSW
Practice Location Address:

415 HIGHWAY 95A , BUILDING I
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1538479365 — KRISTINA J PETTY O.D.
Practice Location Address:

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FERNLEY, NV
89408-9261

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Practice Fax: 775-575-5702

1679883805 — PAM RAMIREZ RN
Practice Location Address:

415 US HIGHWAY 95A S , STE I 901
FERNLEY, NV
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1376845388 — STEPHANIE J LASHUK
Practice Location Address:

415 US HIGHWAY 95A S , STE I 901
FERNLEY, NV
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1750683769 — NANCY JO RUSSELL
Practice Location Address:

415 US HIGHWAY 95A S , STE I 901
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Practice Fax: 775-575-7769

Directions to “STATE OF NEVADA ” Practice Location

Language	Start Address	Practice Location

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