Provider Demographics
NPI:1053204115
Name:STANKE, THERESE
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:STANKE
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 1:11319 LA MADRE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1829
Mailing Address - Country:US
Mailing Address - Phone:702-528-7328
Mailing Address - Fax:
Practice Address - Street 1:916 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-1931
Practice Address - Country:US
Practice Address - Phone:702-202-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV07042-1101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)