Provider Demographics
NPI:1114202629
Name:KLINE, EDITH H (QMHA)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:H
Last Name:KLINE
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6616 GAZELLE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2722
Mailing Address - Country:US
Mailing Address - Phone:702-586-8693
Mailing Address - Fax:702-476-2690
Practice Address - Street 1:5715 W ALEXANDER RD
Practice Address - Street 2:SUITE 155
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2800
Practice Address - Country:US
Practice Address - Phone:702-586-8693
Practice Address - Fax:702-476-2690
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV777-L101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV687695Other687695