Healthcare Provider Details

I. General information

NPI: 1679017594
Provider Name (Legal Business Name): STEPHANIE MEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 S MARYLAND PKWY SUITE 311
LAS VEGAS NV
89119-7500
US

IV. Provider business mailing address

3909 S MARYLAND PKWY STE 311
LAS VEGAS NV
89119-7520
US

V. Phone/Fax

Practice location:
  • Phone: 702-985-6501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: