Provider Demographics
NPI:1740726256
Name:REZZAG, ASHLEY LYNN
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNN
Last Name:REZZAG
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 1:2921 N TENAYA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1409
Mailing Address - Country:US
Mailing Address - Phone:702-942-1774
Mailing Address - Fax:702-942-1773
Practice Address - Street 1:911 N BUFFALO DR
Practice Address - Street 2:UNIT 213
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0379
Practice Address - Country:US
Practice Address - Phone:702-942-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV145600645Medicaid