Provider Demographics
NPI:1790282002
Name:COMMUNITY YOUTH INTERALIA
Entity Type:Organization
Organization Name:COMMUNITY YOUTH INTERALIA
Other - Org Name:SEAO INTERALIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIBA
Authorized Official - Suffix:
Authorized Official - Credentials:EDD CMPC-AASP
Authorized Official - Phone:702-328-0459
Mailing Address - Street 1:9082 VINTAGE WINE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4916
Mailing Address - Country:US
Mailing Address - Phone:702-328-0459
Mailing Address - Fax:
Practice Address - Street 1:9082 VINTAGE WINE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-4916
Practice Address - Country:US
Practice Address - Phone:702-328-0459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY YOUTH INTERALIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV667103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty