Provider Demographics
NPI:1972046613
Name:HERVALL, ELIN TERESA
Entity Type:Individual
Prefix:
First Name:ELIN
Middle Name:TERESA
Last Name:HERVALL
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 1:40 QUAIL RUN RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2148
Mailing Address - Country:US
Mailing Address - Phone:415-786-2761
Mailing Address - Fax:
Practice Address - Street 1:2110 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5190
Practice Address - Country:US
Practice Address - Phone:702-270-3219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-16-25798106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician