Provider Demographics
NPI:1407469034
Name:MAPLE STAR NEVADA
Entity Type:Organization
Organization Name:MAPLE STAR NEVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-677-2216
Mailing Address - Street 1:1161 N EL DORADO PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4607
Mailing Address - Country:US
Mailing Address - Phone:520-570-1460
Mailing Address - Fax:
Practice Address - Street 1:855 W 7TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-2745
Practice Address - Country:US
Practice Address - Phone:775-677-2216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAYS HEALTH AND COMMUNITY SUPPORT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health