MEDICARE: ST MARY BEHAVIORAL SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist
2	103TM1800X	Intellectual & Developmental Disabilities Psychologist
3	251B00000X	Case Management Agency
4	251S00000X	Community/Behavioral Health Agency
5	261QM0850X	Adult Mental Health Clinic/Center
6	261QM0855X	Adolescent and Children Mental Health Clinic/Center
7	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1437930864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARY BEHAVIORAL SERVICES INC

Provider Business Mailing Address
First Line	:	7728 CORONADO ISLAND ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6298
Country	:	US
Telephone Number	:	702-849-2173
Fax Number	:

Provider Business Practice Location Address
First Line	:	7728 CORONADO ISLAND ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6298
Country	:	US
Telephone Number	:	702-849-2173
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. ISAAC MUTABAZI
Credential	:
Telephone Number	:	702-849-2173

Provider Enumeration Date	:	10/11/2023
Last Update Date	:	10/11/2023

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