Basic Information
| Provider Information | |||||||||
| NPI: | 1396299384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTHIER | ||||||||
| FirstName: | MAIA | ||||||||
| MiddleName: | LAURA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | POTHIER | ||||||||
| OtherFirstName: | MAIA | ||||||||
| OtherMiddleName: | LAURA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2801 S VALLEY VIEW BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891020166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029227015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2801 S VALLEY VIEW BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891020166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029227015 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2016 | ||||||||
| LastUpdateDate: | 08/08/2016 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1881842953 | 05 | NV | MEDICAID |