Provider Demographics
NPI:1407102825
Name:GOOD WEASEL, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GOOD WEASEL
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 1:5250 S RAINBOW BLVD
Mailing Address - Street 2:2144
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-0624
Mailing Address - Country:US
Mailing Address - Phone:505-235-8693
Mailing Address - Fax:
Practice Address - Street 1:5250 S RAINBOW BLVD
Practice Address - Street 2:2144
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-0624
Practice Address - Country:US
Practice Address - Phone:505-235-8693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst