Provider Demographics
NPI:1235795824
Name:AVANT-GARDE CENTER FOR WELLNESS
Entity Type:Organization
Organization Name:AVANT-GARDE CENTER FOR WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,MSN,MA,PMHNP-BC
Authorized Official - Phone:323-252-4569
Mailing Address - Street 1:1510 W SUNSET RD STE 110
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2695
Mailing Address - Country:US
Mailing Address - Phone:888-375-8698
Mailing Address - Fax:702-342-8108
Practice Address - Street 1:1510 W SUNSET RD STE 110
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2695
Practice Address - Country:US
Practice Address - Phone:888-375-8698
Practice Address - Fax:702-342-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1235795824Medicaid