Provider Demographics
NPI:1851631196
Name:THERAPY SOURCE OF NEVADA, LLC
Entity Type:Organization
Organization Name:THERAPY SOURCE OF NEVADA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:702-683-7617
Mailing Address - Street 1:2654 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE B5 PMB 322
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2803
Mailing Address - Country:US
Mailing Address - Phone:702-683-7617
Mailing Address - Fax:702-837-3422
Practice Address - Street 1:1614 WATERFORD FALLS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-5873
Practice Address - Country:US
Practice Address - Phone:702-683-7617
Practice Address - Fax:702-837-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-24
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0324225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty