Provider Demographics
NPI:1477338564
Name:EZELL, MAYA L
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:L
Last Name:EZELL
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 1:615 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3342
Mailing Address - Country:US
Mailing Address - Phone:702-461-0620
Mailing Address - Fax:
Practice Address - Street 1:1024 W OWENS AVE STE B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2520
Practice Address - Country:US
Practice Address - Phone:702-636-8729
Practice Address - Fax:702-441-1808
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty