Provider Demographics
NPI:1740540947
Name:TRUCKEE MEADOWS MENTAL HEALTH
Entity type:Organization
Organization Name:TRUCKEE MEADOWS MENTAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:775-857-9599
Mailing Address - Street 1:9695 SILVER DESERT WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-7598
Mailing Address - Country:US
Mailing Address - Phone:775-997-5365
Mailing Address - Fax:775-622-4798
Practice Address - Street 1:4051 KINGS ROW
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-6825
Practice Address - Country:US
Practice Address - Phone:775-997-5365
Practice Address - Fax:775-622-4798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVE0146102012-5320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness