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General NPI Number Information
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NPI Number | 1790282002
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Entity Type | Organization
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Legal Business Name | COMMUNITY YOUTH INTERALIA
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Dates
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Enumeration Date | 04/12/2018
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Last Update Date | 04/12/2018
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Provider Practice Location Address
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Address Line | 9082 VINTAGE WINE AVE
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City | LAS VEGAS
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State | NV
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Zip | 89148-4916
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Country | US
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Telephone | 702-328-0459
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Fax |
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Provider Business Mailing Address
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Address Line | 9082 VINTAGE WINE AVE
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City | LAS VEGAS
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State | NV
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Zip | 89148-4916
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Country | US
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Telephone | 702-328-0459
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUDE NIBA
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Credential | ED.D CMPC-AASP
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Telephone | 702-328-0459
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TE1100X
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Taxonomy Name | Exercise & Sports Psychologist
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License Number | 667
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License Number State | NV
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