Provider Demographics
NPI:1093451650
Name:MKRYAN, LUCY
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:MKRYAN
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 1:6350 S RILEY ST APT 204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1343
Mailing Address - Country:US
Mailing Address - Phone:818-746-6609
Mailing Address - Fax:
Practice Address - Street 1:6350 S RILEY ST APT 204
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-1343
Practice Address - Country:US
Practice Address - Phone:818-746-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV204909106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAJQC94223523DMedicaid