Provider Demographics
NPI:1952048324
Name:ANDERSON, NICOLETTE ROSHANDA
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:ROSHANDA
Last Name:ANDERSON
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 1:5833 CLEAR HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6858
Mailing Address - Country:US
Mailing Address - Phone:702-372-9430
Mailing Address - Fax:
Practice Address - Street 1:1855 E SOUTHERN AVE STE 109
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5227
Practice Address - Country:US
Practice Address - Phone:480-809-6459
Practice Address - Fax:480-809-6469
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician