MEDICARE: DYNAMIC FAMILY THERAPIES

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1477928356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC FAMILY THERAPIES

Provider Business Mailing Address
First Line	:	2110 E FLAMINGO RD STE 317
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5193
Country	:	US
Telephone Number	:	702-410-8400
Fax Number	:	702-410-8401

Provider Business Practice Location Address
First Line	:	2110 E FLAMINGO RD STE 317
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5193
Country	:	US
Telephone Number	:	702-410-8400
Fax Number	:	702-410-8401

Authorized Official
Title or Position	:	MANAGER OF OPERATIONS
Name	:	LEONARD CROOM
Credential	:
Telephone Number	:	702-410-8400

Provider Enumeration Date	:	12/03/2015
Last Update Date	:	12/03/2015

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Directions to “DYNAMIC FAMILY THERAPIES ” Practice Location

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