MEDICARE: BRENT PORADISH CADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	00788C	NV
2	101YM0800X	Mental Health Counselor	00788C	NV

General Provider Information

NPI Number	:	1245790245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT PORADISH CADC

Provider Business Mailing Address
First Line	:	3321 N BUFFALO DR
Second Line	:	SUITE 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89129
Country	:	US
Telephone Number	:	702-868-5800
Fax Number	:

Provider Business Practice Location Address
First Line	:	3371 N BUFFALO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129
Country	:	US
Telephone Number	:	702-515-1373
Fax Number	:

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

Provider Enumeration Date	:	03/25/2019
Last Update Date	:	03/25/2019

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Directions to “ BRENT PORADISH CADC” Practice Location

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