Provider Demographics
NPI:1891244877
Name:WALLEEN-SANDERS, KODY DEAN (RBT)
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:DEAN
Last Name:WALLEEN-SANDERS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1636
Mailing Address - Country:US
Mailing Address - Phone:702-742-4248
Mailing Address - Fax:
Practice Address - Street 1:7261 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1636
Practice Address - Country:US
Practice Address - Phone:702-742-4248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV177029106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician