Healthcare Provider Details

I. General information

NPI: 1194024752
Provider Name (Legal Business Name): MELISSA DALE WADSWORTH LMFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3529 DOVER BAY ST
LAS VEGAS NV
89129-2131
US

IV. Provider business mailing address

3529 DOVER BAY ST
LAS VEGAS NV
89129-2131
US

V. Phone/Fax

Practice location:
  • Phone: 702-485-9917
  • Fax:
Mailing address:
  • Phone: 702-485-9917
  • Fax: 702-982-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM10548
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: