MEDICARE: HEAVENLY MIND LLC

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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1811681232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY MIND LLC

Provider Business Mailing Address
First Line	:	5821 ALISA ROBERTS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-4410
Country	:	US
Telephone Number	:	760-539-6205
Fax Number	:

Provider Business Practice Location Address
First Line	:	5821 ALISA ROBERTS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-4410
Country	:	US
Telephone Number	:	760-539-6205
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALICIA GUTIERREZ VILLEGAS
Credential	:
Telephone Number	:	760-539-6205

Provider Enumeration Date	:	06/07/2023
Last Update Date	:	06/07/2023

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Directions to “HEAVENLY MIND LLC ” Practice Location

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