=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790090181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEMPORARY ASSISTANCE FOR DOMESTIC CRISIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2010
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 MEADOWS LN
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-877-0133
-----------------------------------------------------
Fax | 721-821-2772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 MEADOWS LN
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-877-0133
-----------------------------------------------------
Fax | 702-877-2772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER / HR
-----------------------------------------------------
Name | ERIC RUST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-821-2722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 0271
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------