MEDICARE: PHILLIP D SOLE JR. C.M.T.,N.A.A.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1134790355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP D SOLE JR. C.M.T.,N.A.A.

Provider Business Mailing Address
First Line	:	5645 BRECKENRIDGE ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-2421
Country	:	US
Telephone Number	:	702-937-5327
Fax Number	:

Provider Business Practice Location Address
First Line	:	5645 BRECKENRIDGE ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-2421
Country	:	US
Telephone Number	:	702-937-5327
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	07/08/2021

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