MEDICARE: LISA A DURETTE MD PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103T00000X	Psychologist
3	1041C0700X	Clinical Social Worker
4	106H00000X	Marriage & Family Therapist
5	2084P0804X	Child & Adolescent Psychiatry Physician

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	:	1669679205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA A DURETTE MD PLLC

Provider Business Mailing Address
First Line	:	840 S RANCHO DR STE 4-337
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-3837
Country	:	US
Telephone Number	:	702-440-8840
Fax Number	:	866-518-0781

Provider Business Practice Location Address
First Line	:	6600 W CHARLESTON BLVD STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1067
Country	:	US
Telephone Number	:	702-359-9404
Fax Number	:	866-518-0781

Authorized Official
Title or Position	:	CEO
Name	:	DR. KENNETH MCKAY
Credential	:	PH.D.
Telephone Number	:	702-419-8920

Provider Enumeration Date	:	06/28/2007
Last Update Date	:	11/21/2022

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