MEDICARE: MOTIVATED MIRACLES BEHAVORIAL HEALTH SERVICES

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	251S00000X	Community/Behavioral Health Agency	NV20131681054	NV

General Provider Information

NPI Number	:	1700203239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOTIVATED MIRACLES BEHAVORIAL HEALTH SERVICES

Provider Business Mailing Address
First Line	:	8892 OCEANSIDE SLOPES AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-7524
Country	:	US
Telephone Number	:	702-204-8332
Fax Number	:

Provider Business Practice Location Address
First Line	:	8892 OCEANSIDE SLOPES AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-7524
Country	:	US
Telephone Number	:	702-204-8332
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEANDREA STANSBERRY
Credential	:
Telephone Number	:	702-204-8332

Provider Enumeration Date	:	03/21/2014
Last Update Date	:	03/21/2014

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