Healthcare Provider Details

I. General information

NPI: 1750678199
Provider Name (Legal Business Name): INNOVATION BEHAVIORAL HEALTH SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 PASEO DEL PRADO STE D305
LAS VEGAS NV
89102-4342
US

IV. Provider business mailing address

1876 VERDE MIRADA DR
LAS VEGAS NV
89115-3844
US

V. Phone/Fax

Practice location:
  • Phone: 866-604-6812
  • Fax:
Mailing address:
  • Phone: 702-541-3563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: MRS. SANDRA GRAY
Title or Position: OWNER/CEO
Credential: B.A.; M.S. STUDENT
Phone: 702-541-3563