MEDICARE: MENTAL EDGE THERAPY PROFESSIONAL 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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1447850144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTAL EDGE THERAPY PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	6362 MCLEOD DR STE 6
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-4433
Country	:	US
Telephone Number	:	702-483-1990
Fax Number	:	702-831-8812

Provider Business Practice Location Address
First Line	:	6362 MCLEOD DR STE 6
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-4433
Country	:	US
Telephone Number	:	702-483-1990
Fax Number	:	702-831-8812

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. NICOLE L MCDONAGH
Credential	:	CP, LCADC, LCADC-S
Telephone Number	:	702-483-1990

Provider Enumeration Date	:	10/30/2020
Last Update Date	:	01/06/2025

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