Healthcare Provider Details

I. General information

NPI: 1285294751
Provider Name (Legal Business Name): ANGEL HEARTS MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S RANCHO DR STE D19
LAS VEGAS NV
89106-4832
US

IV. Provider business mailing address

501 S RANCHO DR STE D19
LAS VEGAS NV
89106-4832
US

V. Phone/Fax

Practice location:
  • Phone: 702-767-0361
  • Fax: 702-553-3484
Mailing address:
  • Phone: 702-767-0361
  • Fax: 702-553-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KARSTEN LEIGH MERRICK
Title or Position: CEO
Credential:
Phone: 702-767-0361