Provider Demographics
NPI:1851031223
Name:MYSTIC BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:MYSTIC BEHAVIORAL HEALTH SERVICES
Other - Org Name:MYSTIC BEHAVIORAL HEALTH SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-200-6402
Mailing Address - Street 1:2285 RENAISSANCE DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6754
Mailing Address - Country:US
Mailing Address - Phone:725-200-6402
Mailing Address - Fax:
Practice Address - Street 1:2285 RENAISSANCE DR STE B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6754
Practice Address - Country:US
Practice Address - Phone:725-200-6402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-31
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health