Provider Demographics
NPI:1720343536
Name:KAKAVULIAS, CHRISTINE G
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:G
Last Name:KAKAVULIAS
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 1:5130 S PECOS RD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1248
Mailing Address - Country:US
Mailing Address - Phone:702-900-7397
Mailing Address - Fax:888-753-3302
Practice Address - Street 1:5130 S PECOS RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1248
Practice Address - Country:US
Practice Address - Phone:702-900-7397
Practice Address - Fax:888-753-3302
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV90-0837799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV90-0837799Medicaid