Provider Demographics
NPI:1982900619
Name:STUCKEY, CARNELL LEMONT
Entity type:Individual
Prefix:
First Name:CARNELL
Middle Name:LEMONT
Last Name:STUCKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 W ROME BLVD
Mailing Address - Street 2:3181
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-5497
Mailing Address - Country:US
Mailing Address - Phone:309-444-0063
Mailing Address - Fax:
Practice Address - Street 1:4325 W ROME BLVD
Practice Address - Street 2:3181
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-5497
Practice Address - Country:US
Practice Address - Phone:309-444-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid