Provider Demographics
NPI:1790089209
Name:ST. JUDE'S RANCH FOR CHILDREN
Entity Type:Organization
Organization Name:ST. JUDE'S RANCH FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:702-294-7135
Mailing Address - Street 1:PO BOX 60100
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89006-0100
Mailing Address - Country:US
Mailing Address - Phone:702-294-7100
Mailing Address - Fax:702-294-7171
Practice Address - Street 1:100 SAINT JUDES ST
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1614
Practice Address - Country:US
Practice Address - Phone:702-294-7100
Practice Address - Fax:702-294-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005043433Medicaid
NV9005043441Medicaid