Basic Information
| Provider Information | |||||||||
| NPI: | 1912310368 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRE MENTAL HEALTH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHRISTINE MICHELLE FORMICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 S RAINBOW BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891466531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026737462 | ||||||||
| FaxNumber: | 7024428900 | ||||||||
| Practice Location | |||||||||
| Address1: | 2980 S RAINBOW BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891466531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026737462 | ||||||||
| FaxNumber: | 7024428900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2014 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCANINCH | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7026737462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6553-C | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.