Basic Information
| Provider Information | |||||||||
| NPI: | 1386762664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLAR | ||||||||
| FirstName: | NHU-TAM | ||||||||
| MiddleName: | PHAM | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA LCADC NCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHAM | ||||||||
| OtherFirstName: | NHU-TAM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA LADC NCC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6375 W CHARLESTON BLVD | ||||||||
| Address2: | 172 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028770684 | ||||||||
| FaxNumber: | 7028772108 | ||||||||
| Practice Location | |||||||||
| Address1: | 6375 W CHARLESTON BLVD | ||||||||
| Address2: | STE A-172 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028770684 | ||||||||
| FaxNumber: | 7028772108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 09/15/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 217655 | NV | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 1146 | NV | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | NCC 217655 | 01 | NV | NV NATIOANL BOARD | OTHER | 1146 LCDC | 01 | NV | LICENSE | OTHER | 100500484 | 05 | NV | MEDICAID | 1146 LADC | 01 | NV | LADC LICENSE | OTHER | 3015 | 01 | NV | LICENSE | OTHER |