Provider Demographics
NPI:1114459740
Name:AKHIDENOR, INNOCENT
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:AKHIDENOR
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 1:2270 LOSEE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-4109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2270 LOSEE RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-4109
Practice Address - Country:US
Practice Address - Phone:702-399-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-02
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst