Provider Demographics
NPI:1144671249
Name:REASLAND, TRACI
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:REASLAND
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 1:3278 LIAHONA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5714
Mailing Address - Country:US
Mailing Address - Phone:702-981-1153
Mailing Address - Fax:702-974-4555
Practice Address - Street 1:3278 LIAHONA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5714
Practice Address - Country:US
Practice Address - Phone:702-981-1153
Practice Address - Fax:702-974-4555
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1800731891103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1800731891Medicaid