=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669352886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY MIND SPA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2025
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 VIA MANTOVA UNIT 302
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89011-2267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-487-3650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 VIA MANTOVA UNIT 302
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89011-2267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-487-3650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | QUALIFIED MENTAL HEALTH PROFESSIONA
-----------------------------------------------------
Name | LA TOYA WILKERSON
-----------------------------------------------------
Credential | CPC-I
-----------------------------------------------------
Telephone | 702-487-3650
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------