Healthcare Provider Details

I. General information

NPI: 1073949301
Provider Name (Legal Business Name): LA TANYA DENISE MANOR LCPC-I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 N MARTIN LUTHER KING STE 208
NORTH LAS VEGAS NV
89030
US

IV. Provider business mailing address

3925 N MARTIN LUTHER KING STE 208
NORTH LAS VEGAS NV
89032
US

V. Phone/Fax

Practice location:
  • Phone: 702-814-2012
  • Fax:
Mailing address:
  • Phone: 702-814-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCI3037
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: