Provider Demographics
NPI:1972036564
Name:KIRBY, SANTANA
Entity Type:Individual
Prefix:
First Name:SANTANA
Middle Name:
Last Name:KIRBY
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 1:600 E BONANZA RD
Mailing Address - Street 2:304
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-3039
Mailing Address - Country:US
Mailing Address - Phone:414-574-6654
Mailing Address - Fax:
Practice Address - Street 1:7390 W SAHARA AVE
Practice Address - Street 2:270
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2763
Practice Address - Country:US
Practice Address - Phone:702-852-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVC20170306103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst