MEDICARE: HERNORIA PAL LEA CHILDRESS-SMITH

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	106H00000X	Marriage & Family Therapist	4408	NV

General Provider Information

NPI Number	:	1922399674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HERNORIA PAL LEA CHILDRESS-SMITH

Provider Business Mailing Address
First Line	:	1946 ONA MARIE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-4867
Country	:	US
Telephone Number	:	702-279-4974
Fax Number	:

Provider Business Practice Location Address
First Line	:	7013 FOSSIL RIM ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-4028
Country	:	US
Telephone Number	:	702-573-9715
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2011
Last Update Date	:	03/03/2024

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