Healthcare Provider Details

I. General information

NPI: 1588099865
Provider Name (Legal Business Name): TANEISHA JANAE GRAVES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 01/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3247 S MARYLAND PKWY
LAS VEGAS NV
89109-2412
US

IV. Provider business mailing address

6325 PAGEANT ST
NORTH LAS VEGAS NV
89031-6300
US

V. Phone/Fax

Practice location:
  • Phone: 702-776-3500
  • Fax:
Mailing address:
  • Phone: 702-488-7344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7385-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: