MEDICARE: AZURE D ALEX MFT STATE INTERN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	M14327	NV

General Provider Information

NPI Number	:	1902677560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZURE D ALEX MFT STATE INTERN

Provider Business Mailing Address
First Line	:	2701 N TENAYA WAY STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0480
Country	:	US
Telephone Number	:	702-757-8720
Fax Number	:	702-974-4677

Provider Business Practice Location Address
First Line	:	2701 N TENAYA WAY STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0480
Country	:	US
Telephone Number	:	702-757-8720
Fax Number	:	702-974-4677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2024
Last Update Date	:	01/12/2024

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