Healthcare Provider Details

I. General information

NPI: 1447850144
Provider Name (Legal Business Name): MENTAL EDGE THERAPY PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6362 MCLEOD DR STE 6
LAS VEGAS NV
89120-4433
US

IV. Provider business mailing address

6362 MCLEOD DR STE 6
LAS VEGAS NV
89120-4433
US

V. Phone/Fax

Practice location:
  • Phone: 702-483-1990
  • Fax: 702-831-8812
Mailing address:
  • Phone: 702-483-1990
  • Fax: 702-831-8812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE L MCDONAGH
Title or Position: OWNER
Credential: CP, LCADC, LCADC-S
Phone: 702-483-1990