=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346558913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATIONS OF CHANGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2010
-----------------------------------------------------
Last Update Date | 09/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7468 EASINGWOLD DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89113-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-991-3933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2831 SAINT ROSE PKWY SUITE 213
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-991-3933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. HENRIELLA DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-991-3933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | NV20101336776
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------