MEDICARE: EVOLVING MINDS THERAPY (EMT) 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1285228957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVING MINDS THERAPY (EMT) LLC

Provider Business Mailing Address
First Line	:	5516 BOULDER HWY STE 2F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6000
Country	:	US
Telephone Number	:	702-881-1234
Fax Number	:	651-602-3634

Provider Business Practice Location Address
First Line	:	5516 BOULDER HWY STE 2F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6000
Country	:	US
Telephone Number	:	702-881-1234
Fax Number	:	651-602-3634

Authorized Official
Title or Position	:	OWNER/DIRECTOR/CLINICIAN
Name	:	ZANYAE ALLEN
Credential	:	LCPC
Telephone Number	:	702-937-4848

Provider Enumeration Date	:	02/23/2021
Last Update Date	:	01/04/2022

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