Healthcare Provider Details

I. General information

NPI: 1790108264
Provider Name (Legal Business Name): JOHANNA S. FRICKE, M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N BUFFALO DR SUITE B
LAS VEGAS NV
89145-0375
US

IV. Provider business mailing address

1300 PREMIER CT
LAS VEGAS NV
89117-7134
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-2520
  • Fax: 702-877-2521
Mailing address:
  • Phone: 702-804-9065
  • Fax: 702-877-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number StateNV

VIII. Authorized Official

Name: DR. JOHANNA FRICKE
Title or Position: PHYSICIAN/CEO
Credential: M.D.
Phone: 702-804-9065