Healthcare Provider Details

I. General information

NPI: 1578962924
Provider Name (Legal Business Name): HEALTHY MIND BODY & SPIRIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 E DESERT INN RD STE 200
LAS VEGAS NV
89169-2548
US

IV. Provider business mailing address

1580 E DESERT INN RD STE 200
LAS VEGAS NV
89169-2548
US

V. Phone/Fax

Practice location:
  • Phone: 702-836-3443
  • Fax: 702-836-9367
Mailing address:
  • Phone: 702-836-3443
  • Fax: 702-836-9367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. WANDA NEGRON
Title or Position: PSR/BST
Credential: CADC
Phone: 702-836-3442