1902330780 NPI number — CREATIVE MINDS BEHAVIORAL HEALTH

Table of content: DR. MELISSA JEAN VODICKA DNP, APRN, CPNP (NPI 1245841436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902330780 NPI number — CREATIVE MINDS BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE MINDS BEHAVIORAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902330780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1809 LUNA ALEGRE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89115-7368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-201-8105
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1809 LUNA ALEGRE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89115-7368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-201-8105
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
PRENISE
Authorized Official Middle Name:
APRIL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
702-201-8105

Provider Taxonomy Codes

  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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