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General NPI Number Information
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NPI Number | 1083420244
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Entity Type | Organization
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Legal Business Name | LEGACY MENTAL HEALTH SERVICES PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 12/03/2024
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Last Update Date | 12/09/2024
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Provider Practice Location Address
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Address Line | 2850 W HORIZON RIDGE PKWY STE 200
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City | HENDERSON
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State | NV
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Zip | 89052-4395
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Country | US
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Telephone | 702-605-7018
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Fax |
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Provider Business Mailing Address
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Address Line | 12267 HARVEST SKY WAY UNIT 3
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City | LAS VEGAS
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State | NV
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Zip | 89183-5974
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Country | US
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Telephone | 310-251-6727
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. TYISHA RENEE FLETCHER
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Credential | PMHNP
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Telephone | 702-605-7018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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