MEDICARE: LIFESPAN BEHAVIORAL HEALTH NEVADA PC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1881468890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESPAN BEHAVIORAL HEALTH NEVADA PC

Provider Business Mailing Address
First Line	:	2401 W HORIZON RIDGE PKWY STE 110
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-2707
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 W HORIZON RIDGE PKWY STE 110
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-2707
Country	:	US
Telephone Number	:	725-500-5785
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOSHUA SUSSAL
Credential	:
Telephone Number	:	301-982-3437

Provider Enumeration Date	:	11/09/2023
Last Update Date	:	08/19/2024

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