Basic Information
Provider Information | |||||||||
NPI: | 1972501021 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATE OF NEVADA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHERN NEVADA ADULT MENTAL HEALTH SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 480 GALLETTI WAY | ||||||||
Address2: |   | ||||||||
City: | SPARKS | ||||||||
State: | NV | ||||||||
PostalCode: | 89431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7756880400 | ||||||||
FaxNumber: | 7756880434 | ||||||||
Practice Location | |||||||||
Address1: | 480 GALLETTI WAY | ||||||||
Address2: |   | ||||||||
City: | SPARKS | ||||||||
State: | NV | ||||||||
PostalCode: | 894315564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7756880400 | ||||||||
FaxNumber: | 7756880434 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 07/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BYRD | ||||||||
AuthorizedOfficialFirstName: | HELEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM AGENCY MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7756883321 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | JD, LCSW | ||||||||
NPICertificationDate: | 07/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 652HOS-14 | NV | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 283Q00000X |   |   | Y |   | Hospitals | Psychiatric Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 100503395 | 05 | NV |   | MEDICAID | 001416864 | 05 | NV |   | MEDICAID | VN29400029400 | 01 | NV | MEDICARE/MEDICARE PIN | OTHER | 002016864 | 05 | NV |   | MEDICAID | 100501303 | 05 | NV |   | MEDICAID | 002816864 | 05 | NV |   | MEDICAID | 001316864 | 05 | NV |   | MEDICAID | 005416864 | 05 | NV |   | MEDICAID |