Provider Demographics
NPI:1023402724
Name:BUENROSTRO, IVANKA
Entity Type:Individual
Prefix:
First Name:IVANKA
Middle Name:
Last Name:BUENROSTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8838 TOMNITZ AVE
Mailing Address - Street 2:#103
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-6741
Mailing Address - Country:US
Mailing Address - Phone:702-265-5031
Mailing Address - Fax:
Practice Address - Street 1:8838 TOMNITZ AVE
Practice Address - Street 2:#103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-6741
Practice Address - Country:US
Practice Address - Phone:702-265-5031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1982975009Medicaid