Provider Demographics
NPI:1215595319
Name:NEAL, SHANTA
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:
Last Name:NEAL
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 1:9445 CORAL BERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-5832
Mailing Address - Country:US
Mailing Address - Phone:702-544-8742
Mailing Address - Fax:
Practice Address - Street 1:9445 CORAL BERRY ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-5832
Practice Address - Country:US
Practice Address - Phone:702-544-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA