MEDICARE: SERENITY MIND SPA

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	101YP2500X	Professional Counselor	101YP2500X	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265930549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY MIND SPA

Provider Business Mailing Address
First Line	:	7495 W AZURE DR STE 237
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-4437
Country	:	US
Telephone Number	:	702-680-9350
Fax Number	:

Provider Business Practice Location Address
First Line	:	7495 W AZURE DR STE 237
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-4437
Country	:	US
Telephone Number	:	702-680-9350
Fax Number	:

Authorized Official
Title or Position	:	CPC-I
Name	:	MRS. LA TOYA WILLIAMS
Credential	:	QMHP
Telephone Number	:	702-680-9350

Provider Enumeration Date	:	02/01/2018
Last Update Date	:	06/11/2019

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Directions to “SERENITY MIND SPA ” Practice Location

Language	Start Address	Practice Location

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