MEDICARE: CROSSROADS WELLNESS, 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	125-LC	NV
2	106H00000X	Marriage & Family Therapist	1117	NV

General Provider Information

NPI Number	:	1831411149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS WELLNESS, LLC

Provider Business Mailing Address
First Line	:	7465 W LAKE MEAD BLVD
Second Line	:	STE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1032
Country	:	US
Telephone Number	:	702-480-4891
Fax Number	:	702-562-1221

Provider Business Practice Location Address
First Line	:	7465 W LAKE MEAD BLVD
Second Line	:	STE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1032
Country	:	US
Telephone Number	:	702-480-4891
Fax Number	:	702-562-1221

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. CHAD LEE CROSS
Credential	:	PHD
Telephone Number	:	702-480-4891

Provider Enumeration Date	:	03/01/2010
Last Update Date	:	01/20/2011

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