Healthcare Provider Details

I. General information

NPI: 1538543566
Provider Name (Legal Business Name): OUR LITTLE WORLD TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

165 VITALE AVE
HENDERSON NV
89002-9208
US

V. Phone/Fax

Practice location:
  • Phone: 702-376-2838
  • Fax: 702-933-9122
Mailing address:
  • Phone: 702-376-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY0522
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: SALVADORA GODOROV
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 702-376-2838