Provider Demographics
NPI:1821480161
Name:SHADID, CARLY (MFT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:SHADID
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4464 DE FOREST ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4209
Mailing Address - Country:US
Mailing Address - Phone:702-337-2866
Mailing Address - Fax:
Practice Address - Street 1:1830 E SAHARA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104
Practice Address - Country:US
Practice Address - Phone:702-383-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1004106H00000X
NVMI0589106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1004OtherNV BOARD OF MFT AND CPC
NV1004OtherNV BOARD OF MFT AND CPC