MEDICARE: SQUARE ONE BEHAVIORAL HEALTH

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1326641770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SQUARE ONE BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	2923 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1925
Country	:	US
Telephone Number	:	702-292-0353
Fax Number	:

Provider Business Practice Location Address
First Line	:	2923 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1925
Country	:	US
Telephone Number	:	702-232-0353
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	EAPREL INMAN
Credential	:	N/A
Telephone Number	:	702-292-0353

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	11/18/2020

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