Healthcare Provider Details

I. General information

NPI: 1801330626
Provider Name (Legal Business Name): VIVIAN LETICIA STOVALL PSY.D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 E WARM SPRINGS RD STE 115
LAS VEGAS NV
89119-4680
US

IV. Provider business mailing address

8414 FARM RD STE 180
LAS VEGAS NV
89131-8171
US

V. Phone/Fax

Practice location:
  • Phone: 702-546-9600
  • Fax: 702-829-8065
Mailing address:
  • Phone: 702-546-9600
  • Fax: 702-829-8065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016144
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0844
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: