Provider Demographics
NPI:1083026058
Name:VIVARELLI, NADINE
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:
Last Name:VIVARELLI
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 1:2655 S RAIBOW BLVD
Mailing Address - Street 2:#407
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5100
Mailing Address - Country:US
Mailing Address - Phone:702-750-2682
Mailing Address - Fax:702-750-9180
Practice Address - Street 1:2655 S RAIBOW BLVD
Practice Address - Street 2:#407
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5100
Practice Address - Country:US
Practice Address - Phone:702-750-2682
Practice Address - Fax:702-750-9180
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1912294554Medicaid