Basic Information
| Provider Information | |||||||||
| NPI: | 1407469034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAPLE STAR NEVADA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 N EL DORADO PL | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205701460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 855 W 7TH ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895032745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756772216 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | POULSON | ||||||||
| AuthorizedOfficialFirstName: | ANTOINETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7756772216 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PATHWAYS HEALTH AND COMMUNITY SUPPORT LLC | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.