Basic Information
| Provider Information | |||||||||
| NPI: | 1922581396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLIS | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6977 LUMINARY DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891194666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028097748 | ||||||||
| FaxNumber: | 7024468188 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S RANCHO DR STE A10 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024374673 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1922581396 | 05 | MI | MEDICAID | 1922581396 | 01 | MI | REGISTERED BEHAVIOR TECHNICIAN | OTHER |