Basic Information
| Provider Information | |||||||||
| NPI: | 1740230010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINNIKIN | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | ILAINE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW MAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 BOW RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891458809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026457313 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4000 E CHARLESTON BLVD | ||||||||
| Address2: | B130 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891046659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029684000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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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 | 1041C0700X | 2173C | NV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100507624 | 05 | NV | MEDICAID |