Provider Demographics
NPI:1073963807
Name:DISCOVERY MIND & WELLNESS CENTER
Entity Type:Organization
Organization Name:DISCOVERY MIND & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAN
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:STOLBERG
Authorized Official - Suffix:IV
Authorized Official - Credentials:MS
Authorized Official - Phone:702-968-9372
Mailing Address - Street 1:2920 S JONES BLVD
Mailing Address - Street 2:#220
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5642
Mailing Address - Country:US
Mailing Address - Phone:702-968-9372
Mailing Address - Fax:
Practice Address - Street 1:2920 S JONES BLVD
Practice Address - Street 2:#220
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5642
Practice Address - Country:US
Practice Address - Phone:702-968-9372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1487997805Medicaid