Provider Demographics
NPI:1699382424
Name:ANGELIC SOLUTION WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:ANGELIC SOLUTION WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LYNETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFTI
Authorized Official - Phone:702-401-4003
Mailing Address - Street 1:3600 MONARCAS ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-8718
Mailing Address - Country:US
Mailing Address - Phone:702-401-4003
Mailing Address - Fax:
Practice Address - Street 1:3600 MONARCAS ST UNIT 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-8718
Practice Address - Country:US
Practice Address - Phone:702-401-4003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1205133840Medicaid