MEDICARE: SERENITY PSYCHOSOCIAL SERVICES

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	251S00000X	Community/Behavioral Health Agency	PY0572	NV

General Provider Information

NPI Number	:	1528200631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY PSYCHOSOCIAL SERVICES

Provider Business Mailing Address
First Line	:	2029 WINTER WIND ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6699
Country	:	US
Telephone Number	:	702-343-4420
Fax Number	:	702-543-2000

Provider Business Practice Location Address
First Line	:	2029 WINTER WIND ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6699
Country	:	US
Telephone Number	:	702-343-4420
Fax Number	:	702-543-2000

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MS. TONI DENISE HODGES
Credential	:	B.A.
Telephone Number	:	702-308-2288

Provider Enumeration Date	:	04/03/2009
Last Update Date	:	04/03/2009

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