Provider Demographics
NPI:1578857546
Name:CLARK ANDERSON, NINA
Entity Type:Individual
Prefix:MS
First Name:NINA
Middle Name:
Last Name:CLARK ANDERSON
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 1:3925 N MLK BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-7676
Mailing Address - Country:US
Mailing Address - Phone:702-461-1982
Mailing Address - Fax:
Practice Address - Street 1:3925 N MLK BLVD STE 212
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-7676
Practice Address - Country:US
Practice Address - Phone:702-644-6260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6661-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical