Healthcare Provider Details

I. General information

NPI: 1558983361
Provider Name (Legal Business Name): MY MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 N MAIN ST
TONOPAH NV
89049-8904
US

IV. Provider business mailing address

2941 LORELIE ST
PAHRUMP NV
89048-7512
US

V. Phone/Fax

Practice location:
  • Phone: 702-981-9080
  • Fax:
Mailing address:
  • Phone: 702-981-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: EFRAIN RENE MORALES MORENO
Title or Position: CEO
Credential:
Phone: 702-981-9080