=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245621622
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEVADA INTEGRATED BEHAVIORAL SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2015
-----------------------------------------------------
Last Update Date | 02/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1721 E CHARLESTON BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89104-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-515-9680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1721 E CHARLESTON BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89104-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-515-9680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | FESTUS EBONKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-515-9680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | NV20131553514
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------