Provider Demographics
NPI:1164089488
Name:CANDLELIGHT MENTAL HEALTH COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:CANDLELIGHT MENTAL HEALTH COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIBA
Authorized Official - Middle Name:NEOMI
Authorized Official - Last Name:AMEZCUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-738-9064
Mailing Address - Street 1:700 ROCKY TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-0321
Mailing Address - Country:US
Mailing Address - Phone:702-738-9064
Mailing Address - Fax:
Practice Address - Street 1:5258 S EASTERN AVE STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-2327
Practice Address - Country:US
Practice Address - Phone:702-464-5080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20191376022Medicaid