Healthcare Provider Details

I. General information

NPI: 1740575794
Provider Name (Legal Business Name): MAPLE STAR NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E FLAMINGO RD STE S-107
LAS VEGAS NV
89119-7427
US

IV. Provider business mailing address

1050 E FLAMINGO RD STE S-107
LAS VEGAS NV
89119-7427
US

V. Phone/Fax

Practice location:
  • Phone: 702-733-8098
  • Fax: 702-395-6457
Mailing address:
  • Phone: 702-733-8098
  • Fax: 702-395-6457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ROBERT COWAN
Title or Position: REGIONAL DIRECTOR
Credential: MPA, LSW
Phone: 702-733-8098