1326354309 NPI number — SERENITY COUNSELING AND SUPPORT SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326354309 NPI number — SERENITY COUNSELING AND SUPPORT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY COUNSELING AND SUPPORT SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326354309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60561
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89006-0561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-376-0024
Provider Business Mailing Address Fax Number:
702-479-7173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
578 REDRUTH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89178-1282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-376-0024
Provider Business Practice Location Address Fax Number:
702-479-7173
Provider Enumeration Date:
08/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BERGDALE
Authorized Official First Name:
SOMMER
Authorized Official Middle Name:
THYME
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
702-376-0024

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  5554-C , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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