Healthcare Provider Details

I. General information

NPI: 1497189666
Provider Name (Legal Business Name): OUR LITTLE WORLD TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2013
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12231 S EASTERN AVE STE 140 3RD FLOOR
HENDERSON NV
89052-4415
US

IV. Provider business mailing address

12231 S EASTERN AVE STE 140
HENDERSON NV
89052-4415
US

V. Phone/Fax

Practice location:
  • Phone: 702-742-3093
  • Fax:
Mailing address:
  • Phone: 702-742-3093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNV20131474316
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SALVADORA GODOROV
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 702-742-3093