Healthcare Provider Details

I. General information

NPI: 1255676011
Provider Name (Legal Business Name): GRACE RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7729 MAVERICK ST
LAS VEGAS NV
89131-2113
US

IV. Provider business mailing address

7729 MAVERICK ST
LAS VEGAS NV
89131-2113
US

V. Phone/Fax

Practice location:
  • Phone: 702-370-8912
  • Fax:
Mailing address:
  • Phone: 702-370-8912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00202-S
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNV

VIII. Authorized Official

Name: MRS. SUSAN HARDENBROOK
Title or Position: OWNER
Credential: LADC, LADC-S
Phone: 702-370-8912