MEDICARE: THERAVADA MENTAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	NV20171279356	NV
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1114414109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAVADA MENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	1607 E WINDMILL LN STE 300
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-1910
Country	:	US
Telephone Number	:	702-757-8720
Fax Number	:	702-974-4677

Provider Business Practice Location Address
First Line	:	1607 E WINDMILL LN STE 300
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-1910
Country	:	US
Telephone Number	:	702-757-8720
Fax Number	:	702-974-4677

Authorized Official
Title or Position	:	OWNER
Name	:	JESSICA HASS
Credential	:	LCSW
Telephone Number	:	702-757-8720

Provider Enumeration Date	:	04/16/2018
Last Update Date	:	08/18/2022

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