Provider Demographics
NPI:1063715761
Name:DEBRA M DOODKEVITCH
Entity type:Organization
Organization Name:DEBRA M DOODKEVITCH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOODKEVITCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:702-228-8236
Mailing Address - Street 1:5530 KINGS ROW CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4658
Mailing Address - Country:US
Mailing Address - Phone:702-228-8236
Mailing Address - Fax:702-442-7190
Practice Address - Street 1:5600 SPRING MOUNTAIN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-8821
Practice Address - Country:US
Practice Address - Phone:702-228-8236
Practice Address - Fax:702-442-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-19
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5682-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100518693Medicaid
NV100518693Medicaid