Provider Demographics
NPI:1467180935
Name:MOUDARRES, DYANA MARIE
Entity Type:Individual
Prefix:
First Name:DYANA
Middle Name:MARIE
Last Name:MOUDARRES
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 1:3531 E RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2245
Mailing Address - Country:US
Mailing Address - Phone:702-547-9819
Mailing Address - Fax:
Practice Address - Street 1:3531 E RUSSELL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2245
Practice Address - Country:US
Practice Address - Phone:702-547-9819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician