Healthcare Provider Details

I. General information

NPI: 1962717892
Provider Name (Legal Business Name): CHRISTINE M. FORMICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2152 JASPER BLUFF ST UNIT 105
LAS VEGAS NV
89117-5977
US

IV. Provider business mailing address

2152 JASPER BLUFF ST UNIT 105
LAS VEGAS NV
89117-5977
US

V. Phone/Fax

Practice location:
  • Phone: 702-327-2829
  • Fax:
Mailing address:
  • Phone: 702-327-2829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5789-C
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number5789-C
License Number StateNV

VIII. Authorized Official

Name: MS. CHRISTINE MICHELLE FORMICA
Title or Position: DIRECTOR
Credential: MSW
Phone: 702-327-2829