Provider Demographics
NPI:1598015240
Name:NUEVA VIDA MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:NUEVA VIDA MENTAL HEALTH LLC
Other - Org Name:NVMH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARYSOL
Authorized Official - Middle Name:
Authorized Official - Last Name:REZANOV
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:702-659-8827
Mailing Address - Street 1:4170 S DECATUR BLVD STE C1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5863
Mailing Address - Country:US
Mailing Address - Phone:702-659-8827
Mailing Address - Fax:702-852-0984
Practice Address - Street 1:4170 S DECATUR BLVD STE C1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5863
Practice Address - Country:US
Practice Address - Phone:702-659-8827
Practice Address - Fax:702-852-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6215-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1407281561Medicaid
NV1003127499OtherINDIVIDUAL NPI
NV1225338361Medicaid
NV1003116146Medicaid
NV1497120059Medicaid
NV1891867107Medicaid
NV1982056172Medicaid