Basic Information
| Provider Information | |||||||||
| NPI: | 1235421017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUCKER | ||||||||
| FirstName: | EHRAEDA | ||||||||
| MiddleName: | FAITH-NOELLE | ||||||||
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| Credential: | MA, QMHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 S HUALAPAI WAY APT 2128 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891458843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023065000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2820 W CHARLESTON BLVD # C23 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024374673 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 05/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.