Provider Demographics
NPI:1417378662
Name:STUCKEY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STUCKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6650 E RUSSELL RD # R
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-8359
Mailing Address - Country:US
Mailing Address - Phone:702-408-2323
Mailing Address - Fax:
Practice Address - Street 1:6650 E RUSSELL RD # R
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-8359
Practice Address - Country:US
Practice Address - Phone:702-408-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0Medicaid