Healthcare Provider Details

I. General information

NPI: 1043780695
Provider Name (Legal Business Name): PROUD MOMENTS ABA OF NEVADA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9089 S PECOS RD STE 3600
HENDERSON NV
89074-7186
US

IV. Provider business mailing address

350 5TH AVE STE 6115
NEW YORK NY
10118-6002
US

V. Phone/Fax

Practice location:
  • Phone: 702-680-1523
  • Fax:
Mailing address:
  • Phone: 718-215-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MARK A YOST
Title or Position: GENERAL COUNSEL
Credential:
Phone: 718-215-5311