Provider Demographics
NPI:1407519655
Name:WIBOWO, YOLANDA (CPC- I)
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:
Last Name:WIBOWO
Suffix:
Gender:F
Credentials:CPC- I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 SPENCER ST STE A48
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5245
Mailing Address - Country:US
Mailing Address - Phone:702-408-0480
Mailing Address - Fax:
Practice Address - Street 1:4045 SPENCER ST STE A48
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5245
Practice Address - Country:US
Practice Address - Phone:702-408-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health