Provider Demographics
NPI:1912377482
Name:BATTLE-BORN PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:BATTLE-BORN PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:BLACK-BELT PSYCHOLOGICAL SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO & PRIMARY CONSULTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARNEST
Authorized Official - Middle Name:HOWARD-RUDOLPH
Authorized Official - Last Name:BLACKSHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:702-941-0583
Mailing Address - Street 1:5836 BELUGA BAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6843
Mailing Address - Country:US
Mailing Address - Phone:702-941-0583
Mailing Address - Fax:702-518-0966
Practice Address - Street 1:5836 BELUGA BAY ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-6843
Practice Address - Country:US
Practice Address - Phone:702-941-0583
Practice Address - Fax:702-518-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty