Healthcare Provider Details

I. General information

NPI: 1649951484
Provider Name (Legal Business Name): PURPOSEFUL PLAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 RIVER HILLS LN
LAS VEGAS NV
89135-1791
US

IV. Provider business mailing address

11109 RIVER HILLS LN
LAS VEGAS NV
89135-1791
US

V. Phone/Fax

Practice location:
  • Phone: 480-485-9562
  • Fax:
Mailing address:
  • Phone: 480-485-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: JESSICA POOLE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 702-848-6004