Basic Information
| Provider Information | |||||||||
| NPI: | 1932643731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IDOWU | ||||||||
| FirstName: | DORCAS | ||||||||
| MiddleName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3370 SAINT ROSE PKWY APT 215 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024616931 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2110 EAST FLAMINGO RD. STE 150 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022703219 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2016 | ||||||||
| LastUpdateDate: | 12/13/2016 | ||||||||
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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 | 103K00000X | NV | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.