Healthcare Provider Details

I. General information

NPI: 1881060978
Provider Name (Legal Business Name): ELICIA WHITE BST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 KAREN AVE SUITE B203
LAS VEGAS NV
89109-1264
US

IV. Provider business mailing address

6800 E LAKE MEAD BLVD 2029
LAS VEGAS NV
89156-1119
US

V. Phone/Fax

Practice location:
  • Phone: 702-893-2002
  • Fax: 702-369-3334
Mailing address:
  • Phone: 702-689-4702
  • 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: