Basic Information
| Provider Information | |||||||||
| NPI: | 1770968844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | KAYANA | ||||||||
| MiddleName: | IEISHA-MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDERS | ||||||||
| OtherFirstName: | KAYANA | ||||||||
| OtherMiddleName: | IEISHA-MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3016 W CHARLESTON BLVD STE 205 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027802315 | ||||||||
| FaxNumber: | 7028954014 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 S RANCHO DR STE A | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029989505 | ||||||||
| FaxNumber: | 7025277939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 12/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/10/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106S00000X | RBT-18-52418 | NV | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-18-52418 | 01 | NV | BEHAVIOR ANALYST CERTIFICATION BOARD | OTHER | 1770968844 | 05 | NV | MEDICAID |