Provider Demographics
NPI:1679318901
Name:ONTIVEROS MEDINA, CATHERINNE
Entity type:Individual
Prefix:
First Name:CATHERINNE
Middle Name:
Last Name:ONTIVEROS MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 KLAMATH FALLS WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-3006
Mailing Address - Country:US
Mailing Address - Phone:702-305-7953
Mailing Address - Fax:
Practice Address - Street 1:3680 N RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3180
Practice Address - Country:US
Practice Address - Phone:702-646-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health