MEDICARE: PROVIDENT PLACE

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1760049621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENT PLACE

Provider Business Mailing Address
First Line	:	611 SENECA RIDGE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89084-1315
Country	:	US
Telephone Number	:	702-561-3408
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 SENECA RIDGE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89084-1315
Country	:	US
Telephone Number	:	702-561-3408
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATIE SMITH
Credential	:
Telephone Number	:	702-561-3408

Provider Enumeration Date	:	05/24/2019
Last Update Date	:	05/24/2019

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Directions to “PROVIDENT PLACE ” Practice Location

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