Basic Information
| Provider Information | |||||||||
| NPI: | 1932681699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIKRE | ||||||||
| FirstName: | GELELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 924 CAREY GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890304708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028858642 | ||||||||
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| Practice Location | |||||||||
| Address1: | 408 S JONES BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891072658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025028021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 106S00000X | 05 | NV | MEDICAID |