MEDICARE: DESTINIE CLEVELAND PADC CPC-INTERN NCC

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	101YM0800X	Mental Health Counselor	CI5448	NV
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	08182-PC	NV

General Provider Information

NPI Number	:	1740051200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINIE CLEVELAND PADC CPC-INTERN NCC

Provider Business Mailing Address
First Line	:	732 S 6TH ST STE N
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-6928
Country	:	US
Telephone Number	:	702-482-8527
Fax Number	:

Provider Business Practice Location Address
First Line	:	3311 S RAINBOW BLVD STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6596
Country	:	US
Telephone Number	:	702-546-6816
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2024
Last Update Date	:	02/09/2026

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