MEDICARE: PROVIDER PROFILES, INC.

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	106H00000X	Marriage & Family Therapist	0555	NV

General Provider Information

NPI Number	:	1518017342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDER PROFILES, INC.

Provider Business Mailing Address
First Line	:	8350 W SAHARA AVE
Second Line	:	SUITE 130
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-8939
Country	:	US
Telephone Number	:	702-258-5711
Fax Number	:	702-258-1304

Provider Business Practice Location Address
First Line	:	8350 W SAHARA AVE
Second Line	:	SUITE 130
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-8939
Country	:	US
Telephone Number	:	702-258-5711
Fax Number	:	702-258-1304

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MS. OMEGA JODEAN GALLIANO
Credential	:	MFT
Telephone Number	:	702-258-5711

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	08/22/2020

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Directions to “PROVIDER PROFILES, INC. ” Practice Location

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