Healthcare Provider Details

I. General information

NPI: 1669679205
Provider Name (Legal Business Name): LISA A DURETTE MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W CHARLESTON BLVD STE 140
LAS VEGAS NV
89146-1067
US

IV. Provider business mailing address

840 S RANCHO DR STE 4-337
LAS VEGAS NV
89106-3837
US

V. Phone/Fax

Practice location:
  • Phone: 702-359-9404
  • Fax: 866-518-0781
Mailing address:
  • Phone: 702-440-8840
  • Fax: 866-518-0781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH MCKAY
Title or Position: CEO
Credential: PH.D.
Phone: 702-419-8920