Provider Demographics
NPI:1871867739
Name:STIRTON, SHANA
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:STIRTON
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 1:4160 S PECOS RD STE 17
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5027
Mailing Address - Country:US
Mailing Address - Phone:702-396-3464
Mailing Address - Fax:
Practice Address - Street 1:4090 EASTLAKE BLVD
Practice Address - Street 2:
Practice Address - City:WASHOE VALLEY
Practice Address - State:NV
Practice Address - Zip Code:89704-9103
Practice Address - Country:US
Practice Address - Phone:775-671-5528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 101YM0800X
NVCP5106101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1871867739Medicaid