MEDICARE: HALE KOA COUNSELING SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1083351407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALE KOA COUNSELING SERVICES LLC

Provider Business Mailing Address
First Line	:	4045 SPENCER ST STE A48
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5245
Country	:	US
Telephone Number	:	702-439-3215
Fax Number	:

Provider Business Practice Location Address
First Line	:	4045 SPENCER ST STE A48
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5245
Country	:	US
Telephone Number	:	702-439-3215
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL THERAPIST/OWNER
Name	:	ANDREA VENDEIRO
Credential	:	LCSW
Telephone Number	:	702-439-3215

Provider Enumeration Date	:	05/17/2022
Last Update Date	:	05/17/2022

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