Healthcare Provider Details

I. General information

NPI: 1609212182
Provider Name (Legal Business Name): ETERNITY'S PATH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 N HOLLYWOOD BLVD
LAS VEGAS NV
89110-2021
US

IV. Provider business mailing address

5546 CAMINO AL NORTE # 2-333
NORTH LAS VEGAS NV
89031-0805
US

V. Phone/Fax

Practice location:
  • Phone: 702-758-5961
  • Fax:
Mailing address:
  • Phone: 702-540-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberNV20131272872
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberNV20131272872
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberNV20131272872
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberNV20131272872
License Number StateNV
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberNV20131272872
License Number StateNV

VIII. Authorized Official

Name: MRS. SARITA EDWARDS
Title or Position: PRESIDENT
Credential:
Phone: 702-540-8296