Provider Demographics
NPI:1912344227
Name:MENGESHA, KIFLE
Entity Type:Individual
Prefix:
First Name:KIFLE
Middle Name:
Last Name:MENGESHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6767 W TROPICANA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4755
Mailing Address - Country:US
Mailing Address - Phone:702-209-0370
Mailing Address - Fax:702-463-1851
Practice Address - Street 1:6767 W TROPICANA AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4755
Practice Address - Country:US
Practice Address - Phone:702-209-0370
Practice Address - Fax:702-463-1851
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1948Medicaid