=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669046421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XYZ HOLISTIC THERAPY PROF LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2021
-----------------------------------------------------
Last Update Date | 05/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2920 N GREEN VALLEY PKWY STE 314
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89014-0412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-999-8462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2354 BELVEDERE DR
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89014-3657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-497-5308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TINA MERCED
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 702-497-5308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------