MEDICARE: W-HOLISTIC RECOVERY CENTER

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1760943062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W-HOLISTIC RECOVERY CENTER

Provider Business Mailing Address
First Line	:	2525 N DECATUR BLVD STE 2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2976
Country	:	US
Telephone Number	:	702-806-3223
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 N DECATUR BLVD STE 2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2976
Country	:	US
Telephone Number	:	702-806-3223
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL LEE SANTIAGO
Credential	:	LCSW
Telephone Number	:	702-806-3226

Provider Enumeration Date	:	03/28/2019
Last Update Date	:	03/28/2019

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