Healthcare Provider Details

I. General information

NPI: 1790402196
Provider Name (Legal Business Name): MIND POWER BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 E FLAMINGO RD STE 104
LAS VEGAS NV
89121-5070
US

IV. Provider business mailing address

2942 N 24TH ST STE 114
PHOENIX AZ
85016-7849
US

V. Phone/Fax

Practice location:
  • Phone: 510-456-8143
  • Fax:
Mailing address:
  • Phone: 510-456-8143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: CRISTINE HERNANDEZ
Title or Position: CEO
Credential:
Phone: 510-456-8143