=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902218316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CERTIFIED COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2014
-----------------------------------------------------
Last Update Date | 05/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4760 S PECOS RD SUITE 103
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-6038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-979-0725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4760 S PECOS RD SUITE 103
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-6038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-979-0725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MICHAEL COOPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-979-0725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | NV20141334354
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------