Provider Demographics
NPI:1265741540
Name:FOOTMAN, DAHRIN
Entity type:Individual
Prefix:
First Name:DAHRIN
Middle Name:
Last Name:FOOTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9599 W CHARLESTON BLVD APT 1169
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-6670
Mailing Address - Country:US
Mailing Address - Phone:702-241-2967
Mailing Address - Fax:
Practice Address - Street 1:9599 W CHARLESTON BLVD APT 1169
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-6670
Practice Address - Country:US
Practice Address - Phone:702-241-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005056211Medicaid