Provider Demographics
NPI:1891494373
Name:LEDESMA, STACY (CADC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LEDESMA
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:LEDESMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CADC
Mailing Address - Street 1:840 S RANCHO DR STE 4-337
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3837
Mailing Address - Country:US
Mailing Address - Phone:702-440-8840
Mailing Address - Fax:866-518-0781
Practice Address - Street 1:552 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1319
Practice Address - Country:US
Practice Address - Phone:702-440-8440
Practice Address - Fax:866-518-0781
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV07225-S101YA0400X
NV00324-C101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1235633421OtherCOMMERCIAL