Provider Demographics
NPI:1295192995
Name:NEBRE, RYAN JUSTIN (SOCIOLOGY)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JUSTIN
Last Name:NEBRE
Suffix:
Gender:M
Credentials:SOCIOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 WARLING ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-4119
Mailing Address - Country:US
Mailing Address - Phone:702-893-2002
Mailing Address - Fax:
Practice Address - Street 1:1455 E TROPICANA AVE
Practice Address - Street 2:SUITE 175B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6507
Practice Address - Country:US
Practice Address - Phone:702-893-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV464617191Medicaid