=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164607503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTICARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2008
-----------------------------------------------------
Last Update Date | 01/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3923 SHETLAND PONY ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89122-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-807-6844
-----------------------------------------------------
Fax | 702-407-2446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3923 SHETLAND PONY ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89122-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-807-6844
-----------------------------------------------------
Fax | 702-407-2446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MR. DANA CRUMP BROWN
-----------------------------------------------------
Credential | MS, CADC INTERN
-----------------------------------------------------
Telephone | 702-807-6844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 0981-I
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------