Provider Demographics
NPI:1962717892
Name:CHRISTINE M. FORMICA
Entity type:Organization
Organization Name:CHRISTINE M. FORMICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:702-327-2829
Mailing Address - Street 1:2152 JASPER BLUFF ST UNIT 105
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5977
Mailing Address - Country:US
Mailing Address - Phone:702-327-2829
Mailing Address - Fax:
Practice Address - Street 1:2152 JASPER BLUFF ST UNIT 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5977
Practice Address - Country:US
Practice Address - Phone:702-327-2829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5789-C1041C0700X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253J00000XAgenciesFoster Care Agency
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty