Provider Demographics
NPI:1861271850
Name:DIBETTA, MAYRA ANDREA
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:ANDREA
Last Name:DIBETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:ANDREA
Other - Last Name:TAPIA-BURNHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 CASTLE WALL ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1379
Mailing Address - Country:US
Mailing Address - Phone:702-289-8180
Mailing Address - Fax:
Practice Address - Street 1:100 DELMAR GARDENS DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-3216
Practice Address - Country:US
Practice Address - Phone:702-361-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-3758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist