Healthcare Provider Details

I. General information

NPI: 1598038747
Provider Name (Legal Business Name): IDA MEDAGLIA BACH LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 BRIDGE CANYON ST
HENDERSON NV
89015-7649
US

IV. Provider business mailing address

298 BRIDGE CANYON ST
HENDERSON NV
89015-7649
US

V. Phone/Fax

Practice location:
  • Phone: 951-599-5524
  • Fax:
Mailing address:
  • Phone: 951-599-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number79275
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4812-R
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: