Provider Demographics
NPI:1881060978
Name:WHITE, ELICIA (BST)
Entity type:Individual
Prefix:MS
First Name:ELICIA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:BST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 E LAKE MEAD BLVD
Mailing Address - Street 2:2029
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-1119
Mailing Address - Country:US
Mailing Address - Phone:702-689-4702
Mailing Address - Fax:
Practice Address - Street 1:900 KAREN AVE
Practice Address - Street 2:SUITE B203
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-1264
Practice Address - Country:US
Practice Address - Phone:702-893-2002
Practice Address - Fax:702-369-3334
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV2014064283Medicaid