Healthcare Provider Details

I. General information

NPI: 1013548817
Provider Name (Legal Business Name): ABRAXAS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 W COUGAR AVE STE 300
LAS VEGAS NV
89139-7617
US

IV. Provider business mailing address

4262 BLUE DIAMOND RD # 102-105
LAS VEGAS NV
89139-7789
US

V. Phone/Fax

Practice location:
  • Phone: 702-412-8405
  • Fax:
Mailing address:
  • Phone: 702-412-8405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNY CASINO
Title or Position: CO-FOUNDER
Credential: LCSW
Phone: 702-412-8405