Provider Demographics
NPI:1336882869
Name:NATHAN, TELICIA A
Entity Type:Individual
Prefix:
First Name:TELICIA
Middle Name:A
Last Name:NATHAN
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 1:2200 N TORREY PINES DR APT 2019
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-6506
Mailing Address - Country:US
Mailing Address - Phone:323-338-2255
Mailing Address - Fax:
Practice Address - Street 1:5803 W CRAIG RD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2537
Practice Address - Country:US
Practice Address - Phone:702-901-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician