Healthcare Provider Details

I. General information

NPI: 1366178675
Provider Name (Legal Business Name): THERAPY BEHAVIOR SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8670 W CHEYENNE AVE STE 115
LAS VEGAS NV
89129-7457
US

IV. Provider business mailing address

8670 W CHEYENNE AVE STE 115
LAS VEGAS NV
89129-7457
US

V. Phone/Fax

Practice location:
  • Phone: 725-202-1497
  • Fax: 725-202-1500
Mailing address:
  • Phone: 725-202-1497
  • Fax: 725-202-1500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAWN MANVELL
Title or Position: PRESIDENT, OWNER, SLP
Credential: OWNER, SLP
Phone: 714-943-7146