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General NPI Number Information
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NPI Number | 1851631196
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Entity Type | Organization
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Legal Business Name | THERAPY SOURCE OF NEVADA, LLC
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Dates
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Enumeration Date | 02/24/2013
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Last Update Date | 02/24/2013
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Provider Practice Location Address
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Address Line | 1614 WATERFORD FALLS AVE
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City | LAS VEGAS
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State | NV
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Zip | 89123-5873
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Country | US
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Telephone | 702-683-7617
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Fax | 702-837-3422
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Provider Business Mailing Address
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Address Line | 2654 W HORIZON RIDGE PKWY SUITE B5 PMB 322
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City | HENDERSON
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State | NV
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Zip | 89052-2803
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Country | US
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Telephone | 702-683-7617
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Fax | 702-837-3422
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | SUSAN MINNICK
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Credential | OTR/L
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Telephone | 702-683-7617
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | 0324
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License Number State | NV
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