MEDICARE: DIJANNAI LANETTE MAIDEN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1851974158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIJANNAI LANETTE MAIDEN

Provider Business Mailing Address
First Line	:	1827 W GOWAN RD APT 2044
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-6007
Country	:	US
Telephone Number	:	562-475-8115
Fax Number	:

Provider Business Practice Location Address
First Line	:	1827 W GOWAN RD APT 2044
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-6007
Country	:	US
Telephone Number	:	562-475-8115
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2021
Last Update Date	:	05/04/2021

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Directions to “ DIJANNAI LANETTE MAIDEN ” Practice Location

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