Healthcare Provider Details

I. General information

NPI: 1972833721
Provider Name (Legal Business Name): DIVINE FAMILY ASSISTANCE OF NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9021 VICTOR CREEK AVE
LAS VEGAS NV
89149-3274
US

IV. Provider business mailing address

9021 VICTOR CREEK AVE
LAS VEGAS NV
89149-3274
US

V. Phone/Fax

Practice location:
  • Phone: 702-348-7653
  • Fax:
Mailing address:
  • Phone: 702-348-7653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name: VALESIA COOK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 702-348-7653