Healthcare Provider Details

I. General information

NPI: 1831863315
Provider Name (Legal Business Name): 1111 THERAPY & MENTAL HEALTH INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 BLACKCOMBE ST UNIT 204
LAS VEGAS NV
89128-8019
US

IV. Provider business mailing address

1504 BLACKCOMBE ST UNIT 204
LAS VEGAS NV
89128-8019
US

V. Phone/Fax

Practice location:
  • Phone: 404-849-9918
  • Fax:
Mailing address:
  • Phone: 404-849-9918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: RODNEY BUMPERS
Title or Position: MANAGER
Credential: M.ED
Phone: 404-849-9918