Healthcare Provider Details

I. General information

NPI: 1891204327
Provider Name (Legal Business Name): NANCY ACQUAVIVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W CHARLESTON BLVD STE 140
LAS VEGAS NV
89146-1067
US

IV. Provider business mailing address

3644 S FORT APACHE RD APT 2008
LAS VEGAS NV
89147-3425
US

V. Phone/Fax

Practice location:
  • Phone: 702-437-4673
  • Fax: 702-438-4673
Mailing address:
  • Phone: 702-713-4315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: