Healthcare Provider Details

I. General information

NPI: 1013567585
Provider Name (Legal Business Name): MY THERAPY FE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7341 W CHARLESTON BLVD SUITE #130
LAS VEGAS NV
89117
US

IV. Provider business mailing address

6201 EVENSAIL DR
LAS VEGAS NV
89156-6967
US

V. Phone/Fax

Practice location:
  • Phone: 725-780-4488
  • Fax:
Mailing address:
  • Phone: 702-808-9668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LEONARD LACEY ROSS JR.
Title or Position: OPERATION MANAGER / OWNER
Credential: MFT
Phone: 702-808-9668