Healthcare Provider Details

I. General information

NPI: 1114400934
Provider Name (Legal Business Name): DOMINIC PERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HARRIS SPRINGS RD
LAS VEGAS NV
89124-9215
US

IV. Provider business mailing address

1200 HARRIS SPRINGS RD
LAS VEGAS NV
89124-9215
US

V. Phone/Fax

Practice location:
  • Phone: 702-872-5382
  • Fax:
Mailing address:
  • Phone: 702-872-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number02295-I
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10798-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: