Provider Demographics
NPI:1255679312
Name:NISWONGER PSYCHOLOGICAL HEALTH, LLC
Entity Type:Organization
Organization Name:NISWONGER PSYCHOLOGICAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:NISWONGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:702-768-2950
Mailing Address - Street 1:7495 W AZURE DR
Mailing Address - Street 2:SUITE #204
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-4416
Mailing Address - Country:US
Mailing Address - Phone:702-768-2950
Mailing Address - Fax:
Practice Address - Street 1:7495 W AZURE DR
Practice Address - Street 2:SUITE #204
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-4416
Practice Address - Country:US
Practice Address - Phone:702-768-2950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5436-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty