Healthcare Provider Details

I. General information

NPI: 1407273360
Provider Name (Legal Business Name): P.R.I.D.E. SERVICES L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 E TROPICANA AVE STE 154
LAS VEGAS NV
89119-8316
US

IV. Provider business mailing address

1516 E TROPICANA AVE STE 154
LAS VEGAS NV
89119-8316
US

V. Phone/Fax

Practice location:
  • Phone: 702-268-8109
  • Fax:
Mailing address:
  • Phone: 702-268-8109
  • Fax: 702-268-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberNV20141081108
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANDREA DENISE WALKER-DAVIS
Title or Position: MANAGER
Credential:
Phone: 702-268-8109