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General NPI Number Information
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NPI Number | 1518017342
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Entity Type | Organization
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Legal Business Name | PROVIDER PROFILES, INC.
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8350 W SAHARA AVE SUITE 130
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City | LAS VEGAS
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State | NV
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Zip | 89117-8939
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Country | US
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Telephone | 702-258-5711
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Fax | 702-258-1304
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Provider Business Mailing Address
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Address Line | 8350 W SAHARA AVE SUITE 130
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City | LAS VEGAS
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State | NV
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Zip | 89117-8939
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Country | US
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Telephone | 702-258-5711
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Fax | 702-258-1304
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MS. OMEGA JODEAN GALLIANO
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Credential | MFT
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Telephone | 702-258-5711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0555
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License Number State | NV
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