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General NPI Number Information
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NPI Number | 1386029973
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Entity Type | Organization
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Legal Business Name | PENNYWELL BEHAVIORAL HEALTH CENTER
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Dates
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Enumeration Date | 07/23/2015
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Last Update Date | 07/23/2015
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Provider Practice Location Address
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Address Line | 5025 NELLIS OASIS LN APT 244
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City | LAS VEGAS
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State | NV
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Zip | 89115-0770
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Country | US
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Telephone | 714-499-6232
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Fax |
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Provider Business Mailing Address
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Address Line | 5025 NELLIS OASIS LN APT 244
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City | LAS VEGAS
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State | NV
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Zip | 89115-0770
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Country | US
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Telephone | 714-499-6232
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | PHILLIP WASHINGTON SR.
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Credential |
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Telephone | 714-499-6232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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