Provider Demographics
NPI:1053817221
Name:MAKING A DIFFERENCE IN COMMUNITIES
Entity Type:Organization
Organization Name:MAKING A DIFFERENCE IN COMMUNITIES
Other - Org Name:M.A.D.I.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CARMEA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-533-6008
Mailing Address - Street 1:5920 LAVENDER BREEZE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6848
Mailing Address - Country:US
Mailing Address - Phone:702-533-6008
Mailing Address - Fax:
Practice Address - Street 1:5920 LAVENDER BREEZE ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-6848
Practice Address - Country:US
Practice Address - Phone:702-533-6008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-05
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV251S00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1053817221Medicaid