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NPI Code Detail

MEDICARE: LIVING WATER PSYCHIATRY PLLC

MEDICARE: LIVING WATER PSYCHIATRY PLLC
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number : 1124860929
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIVING WATER PSYCHIATRY PLLC
Provider Business Mailing Address
First Line : 5940 S RAINBOW BLVD
Second Line : SUITE 400 #783517
City : LAS VEGAS
State : NV
Zip : 89118-2507
Country : US
Telephone Number : 702-854-6853
Fax Number : 702-758-7317
Provider Business Practice Location Address
First Line : 5940 S RAINBOW BLVD STE 400
Second Line :
City : LAS VEGAS
State : NV
Zip : 89118-2507
Country : US
Telephone Number : 702-854-6853
Fax Number : 702-758-7315
Authorized Official
Title or Position : CEO
Name : MARJORY FREDERIC
Credential : APRN, PMHNP-BC
Telephone Number : 702-854-6853
Provider Enumeration Date : 06/11/2024
Last Update Date : 06/11/2024

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Directions to “LIVING WATER PSYCHIATRY PLLC ” Practice Location

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