Provider Demographics
NPI:1174277792
Name:FEDORA, HEATHER (MA, MFT-INTERN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FEDORA
Suffix:
Gender:F
Credentials:MA, MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5937 ROUND CASTLE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-4947
Mailing Address - Country:US
Mailing Address - Phone:702-748-7442
Mailing Address - Fax:
Practice Address - Street 1:8360 W SAHARA AVE STE 230
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-8945
Practice Address - Country:US
Practice Address - Phone:702-748-7442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI4066106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist