Healthcare Provider Details

I. General information

NPI: 1831799915
Provider Name (Legal Business Name): MENTAL EDGE THERAPY PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 SAINT ROSE PKWY STE 220A
HENDERSON NV
89074-7789
US

IV. Provider business mailing address

2520 SAINT ROSE PKWY STE 220A
HENDERSON NV
89074-7789
US

V. Phone/Fax

Practice location:
  • Phone: 702-483-1990
  • Fax:
Mailing address:
  • Phone: 702-483-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE MCDONAGH
Title or Position: OWNER
Credential: CPC-I, LADC, C.HT.
Phone: 702-483-1990