Provider Demographics
NPI:1417596024
Name:HOLCOMB, LAUREL AMANDA
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:AMANDA
Last Name:HOLCOMB
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 1:72 BASQUE COAST ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-4669
Mailing Address - Country:US
Mailing Address - Phone:702-290-9994
Mailing Address - Fax:
Practice Address - Street 1:7125 GRAND MONTECITO PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-0260
Practice Address - Country:US
Practice Address - Phone:702-396-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-19-7552-192003106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician