=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316535347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRACTICAL BALANCE COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2021
-----------------------------------------------------
Last Update Date | 07/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7331 W CHARLESTON BLVD STE 140
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-1570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-957-5898
-----------------------------------------------------
Fax | 702-489-7844
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7331 W CHARLESTON BLVD STE 140
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-1570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-957-5898
-----------------------------------------------------
Fax | 702-489-7844
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCPC/OWNER
-----------------------------------------------------
Name | MARY VANDER VEER
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 360-957-5898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------