Basic Information
Provider Information | |||||||||
NPI: | 1538581087 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEQUEL ALLIANCE FAMILY SERVICES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1131 EAGLETREE LN SW | ||||||||
Address2: |   | ||||||||
City: | HUNTSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 358016478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2568803339 | ||||||||
FaxNumber: | 2568809569 | ||||||||
Practice Location | |||||||||
Address1: | 4431 S EASTERN AVE STE 1 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891197850 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7027500377 | ||||||||
FaxNumber: | 7025387928 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2014 | ||||||||
LastUpdateDate: | 01/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CAUDLE | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CBO DIRECTOR OF PATIENT ACCOUNTS | ||||||||
AuthorizedOfficialTelephone: | 2568803339 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SEQUEL TSI HOLDING, LLC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NV20141007166 | NV | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.