Provider Demographics
NPI:1124556543
Name:FAVELA CHAIDEZ, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:FAVELA CHAIDEZ
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 1:3130 S RAINBOW BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6212
Mailing Address - Country:US
Mailing Address - Phone:702-202-3374
Mailing Address - Fax:
Practice Address - Street 1:3035 S JONES BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6766
Practice Address - Country:US
Practice Address - Phone:702-829-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty