Provider Demographics
NPI:1275624645
Name:TICE, SUNNY JEANI (LCSW)
Entity Type:Individual
Prefix:
First Name:SUNNY
Middle Name:JEANI
Last Name:TICE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 DOMNUS LN.
Mailing Address - Street 2:#206
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0855
Mailing Address - Country:US
Mailing Address - Phone:702-375-5500
Mailing Address - Fax:702-360-1161
Practice Address - Street 1:4550 W. OAKEY BLVD.
Practice Address - Street 2:SUITE # 111-Q
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-375-5500
Practice Address - Fax:702-360-1161
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2850-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2850-COtherNV. ST. LIC SOCIAL WORK
NVP49185Medicare UPIN
NVV35893Medicare PIN