=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093485336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHOLISTIC RECOVERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2021
-----------------------------------------------------
Last Update Date | 09/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2580 N RANCHO DR STE 105
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89130-3361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-981-0289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2580 N RANCHO DR STE 105
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89130-3361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-981-0289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MS. LUCIA CAROL MATTHEW
-----------------------------------------------------
Credential | CPC-INTERN
-----------------------------------------------------
Telephone | 707-981-0289
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------