Healthcare Provider Details

I. General information

NPI: 1417596024
Provider Name (Legal Business Name): LAUREL AMANDA HOLCOMB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 GRAND MONTECITO PKWY
LAS VEGAS NV
89149-0260
US

IV. Provider business mailing address

72 BASQUE COAST ST
LAS VEGAS NV
89138-4669
US

V. Phone/Fax

Practice location:
  • Phone: 702-396-0101
  • Fax:
Mailing address:
  • Phone: 702-290-9994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-7552-192003
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: