Healthcare Provider Details

I. General information

NPI: 1316242985
Provider Name (Legal Business Name): LURLINE WELLS MFT-I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 W CHARLESTON BLVD #23
LAS VEGAS NV
89102-1942
US

IV. Provider business mailing address

2820 W CHARLESTON BLVD #23
LAS VEGAS NV
89102-1942
US

V. Phone/Fax

Practice location:
  • Phone: 702-437-4673
  • Fax: 702-438-4673
Mailing address:
  • Phone: 702-437-4673
  • Fax: 702-438-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number01255-L
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMI0765
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: