Provider Demographics
NPI:1881196277
Name:WATERFALL BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:WATERFALL BEHAVIORAL HEALTH SERVICES
Other - Org Name:WATERFALL BEHAVIORAL HEALTH SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOQUETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-929-6316
Mailing Address - Street 1:4760 S PECOS RD STE 103-19
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-6038
Mailing Address - Country:US
Mailing Address - Phone:702-207-1005
Mailing Address - Fax:
Practice Address - Street 1:4760 S PECOS RD STE 103-19
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-6038
Practice Address - Country:US
Practice Address - Phone:702-207-1005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20181152974251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1538530514Medicaid