Provider Demographics
NPI:1013330695
Name:PRO-HEALTH THERAPEUTIC & EMPOWERMENT SERVICES LLC
Entity Type:Organization
Organization Name:PRO-HEALTH THERAPEUTIC & EMPOWERMENT SERVICES LLC
Other - Org Name:PRO-HEALTH WELLNESS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:702-490-9009
Mailing Address - Street 1:2620 S MARYLAND PKWY # 14-199
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-8300
Mailing Address - Country:US
Mailing Address - Phone:702-490-9009
Mailing Address - Fax:866-737-6147
Practice Address - Street 1:3376 S EASTERN AVE # 188A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-3380
Practice Address - Country:US
Practice Address - Phone:702-490-9009
Practice Address - Fax:866-737-6147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-02
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1015873316Medicaid
NV1063780500Medicaid