Provider Demographics
NPI:1245695949
Name:CONNER, ERICA SHANTE'
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:SHANTE'
Last Name:CONNER
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 1:2500 TEDDY DR
Mailing Address - Street 2:BUILDING 2713
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-6481
Mailing Address - Country:US
Mailing Address - Phone:702-443-2423
Mailing Address - Fax:
Practice Address - Street 1:2500 TEDDY DR
Practice Address - Street 2:BUILDING 2713
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-6481
Practice Address - Country:US
Practice Address - Phone:702-443-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00000006717Medicaid