Healthcare Provider Details

I. General information

NPI: 1174948160
Provider Name (Legal Business Name): RENISE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3455
US

IV. Provider business mailing address

5008 TROPICAL GLEN CT
LAS VEGAS NV
89130-7228
US

V. Phone/Fax

Practice location:
  • Phone: 702-385-5678
  • Fax:
Mailing address:
  • Phone: 323-841-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: