Provider Demographics
NPI:1982302873
Name:FEAZELL, ELANTRA
Entity Type:Individual
Prefix:
First Name:ELANTRA
Middle Name:
Last Name:FEAZELL
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 1:4225 MIDDLESEX AVE APT B
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-5761
Mailing Address - Country:US
Mailing Address - Phone:702-904-5299
Mailing Address - Fax:
Practice Address - Street 1:4225 MIDDLESEX AVE APT B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5761
Practice Address - Country:US
Practice Address - Phone:702-904-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health