Healthcare Provider Details

I. General information

NPI: 1003553678
Provider Name (Legal Business Name): CENTRO YOLITIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 E RUSSELL RD STE 104
LAS VEGAS NV
89120-2201
US

IV. Provider business mailing address

3450 E RUSSELL RD STE 104
LAS VEGAS NV
89120-2201
US

V. Phone/Fax

Practice location:
  • Phone: 702-292-7026
  • Fax:
Mailing address:
  • Phone: 702-292-7026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. GERARDO WENCE-MUNOZ
Title or Position: CLINICAL DIRECTOR/OWNER
Credential: LCPC
Phone: 702-292-7026