=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699350579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARADOXIQ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2021
-----------------------------------------------------
Last Update Date | 03/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6910 S CIMARRON RD # 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89113-2280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-664-1499
-----------------------------------------------------
Fax | 702-664-1499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4262 BLUE DIAMOND RD # 102-105
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89139-7789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-521-8565
-----------------------------------------------------
Fax | 702-664-1499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | SYDNEY SMITH
-----------------------------------------------------
Credential | MS, LPC
-----------------------------------------------------
Telephone | 918-521-8565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------