Healthcare Provider Details

I. General information

NPI: 1477338564
Provider Name (Legal Business Name): MAYA L EZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 W OWENS AVE STE B
LAS VEGAS NV
89106-2520
US

IV. Provider business mailing address

615 JEFFERSON AVE
LAS VEGAS NV
89106-3342
US

V. Phone/Fax

Practice location:
  • Phone: 702-636-8729
  • Fax: 702-441-1808
Mailing address:
  • Phone: 702-461-0620
  • 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: