Healthcare Provider Details

I. General information

NPI: 1972415313
Provider Name (Legal Business Name): PROVOST BODY & MIND, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 WHITNEY RANCH DR APT 1811
HENDERSON NV
89014-2616
US

IV. Provider business mailing address

650 WHITNEY RANCH DR APT 1811
HENDERSON NV
89014-2616
US

V. Phone/Fax

Practice location:
  • Phone: 702-661-6424
  • Fax:
Mailing address:
  • Phone: 702-661-6424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KATELIN M PROVOST
Title or Position: CEO
Credential: LCSW
Phone: 775-420-2226