Provider Demographics
NPI:1447758487
Name:BROOKS GARCIA, TALIA AMALIA
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:AMALIA
Last Name:BROOKS GARCIA
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 1:5320 PADUA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-0404
Mailing Address - Country:US
Mailing Address - Phone:702-472-1975
Mailing Address - Fax:
Practice Address - Street 1:4550 W OAKEY BLVD STE 111-O
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1581
Practice Address - Country:US
Practice Address - Phone:702-861-0238
Practice Address - Fax:702-938-5896
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NVNV20161065817376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1821520016Medicaid