Healthcare Provider Details

I. General information

NPI: 1053962027
Provider Name (Legal Business Name): HABTAMUA FEKADU ASSORE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W CHARLESTON BLVD STE 140
LAS VEGAS NV
89146-1067
US

IV. Provider business mailing address

6600 W CHARLESTON BLVD STE 140
LAS VEGAS NV
89146-1067
US

V. Phone/Fax

Practice location:
  • Phone: 702-437-4673
  • Fax: 702-438-4673
Mailing address:
  • Phone: 702-437-4673
  • Fax: 702-438-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: