Basic Information
| Provider Information | |||||||||
| NPI: | 1982069647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHANEUF | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 ANNABELLE LN APT 154 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890147634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024266756 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7200 E SUNSET RD #24 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022703219 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2015 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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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.