Healthcare Provider Details

I. General information

NPI: 1639656960
Provider Name (Legal Business Name): FELIPE DE LEON PAYUMO LSW, CSW INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3321 N BUFFALO DRIVE SUITE 200
LAS VEGAS NV
89129
US

IV. Provider business mailing address

3321 N BUFFALO DRIVE SUITE 200
LAS VEGAS NV
89129
US

V. Phone/Fax

Practice location:
  • Phone: 702-515-1373
  • Fax: 702-331-3098
Mailing address:
  • Phone: 702-515-1373
  • Fax: 702-331-3098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7598-5
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7598-5
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: