MEDICARE: R.E.S.T.O.R.E. BEHAVIORAL HEALTH REHABILITATIVE TREATMENT 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	103K00000X	Behavior Analyst	20111522035	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386923506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R.E.S.T.O.R.E. BEHAVIORAL HEALTH REHABILITATIVE TREATMENT SERVICES,LLC

Provider Business Mailing Address
First Line	:	3925 NORTH MARTIN LUTHER KING BLVD.
Second Line	:	SUITE 215
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-7676
Country	:	US
Telephone Number	:	404-449-3463
Fax Number	:	702-990-2063

Provider Business Practice Location Address
First Line	:	3925 NORTH MARTIN LUTHER KING BLVD.
Second Line	:	SUITE 215
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-7676
Country	:	US
Telephone Number	:	404-449-3463
Fax Number	:	702-990-2063

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR/CEO
Name	:	MS. RITA MICHELLE BLANKENSHIP
Credential	:	MS, CADC-I
Telephone Number	:	404-449-3463

Provider Enumeration Date	:	08/04/2011
Last Update Date	:	07/14/2014

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