MEDICARE: SUMMERLIN THERAPY & COUPLES COUNSELING

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1952930240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMERLIN THERAPY & COUPLES COUNSELING

Provider Business Mailing Address
First Line	:	5931 ALLANCHE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-0443
Country	:	US
Telephone Number	:	612-986-6853
Fax Number	:

Provider Business Practice Location Address
First Line	:	10655 PARK RUN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89144-4589
Country	:	US
Telephone Number	:	702-625-2342
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	JESSICA RESTUCH
Credential	:	MFT-I
Telephone Number	:	702-625-2342

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	04/07/2020

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