Provider Demographics
NPI:1053860890
Name:DEMICHELE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEMICHELE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3937 SPENCER ST APT 35
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5206
Mailing Address - Country:US
Mailing Address - Phone:914-557-9918
Mailing Address - Fax:
Practice Address - Street 1:3530 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5069
Practice Address - Country:US
Practice Address - Phone:702-816-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2105489684101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2105489684Medicaid