Provider Demographics
NPI:1568869196
Name:PURDY, NICOLE (AA PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PURDY
Suffix:
Gender:F
Credentials:AA PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 E SILVERADO RANCH BLVD APT 2237
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-5896
Mailing Address - Country:US
Mailing Address - Phone:312-545-0701
Mailing Address - Fax:
Practice Address - Street 1:875 E SILVERADO RANCH BLVD APT 2237
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-5896
Practice Address - Country:US
Practice Address - Phone:312-545-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV251S00000X104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1154755262Medicaid