Provider Demographics
NPI:1831863315
Name:1111 THERAPY & MENTAL HEALTH INSTITUTE
Entity type:Organization
Organization Name:1111 THERAPY & MENTAL HEALTH INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUMPERS
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:404-849-9918
Mailing Address - Street 1:1504 BLACKCOMBE ST UNIT 204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-8019
Mailing Address - Country:US
Mailing Address - Phone:404-849-9918
Mailing Address - Fax:
Practice Address - Street 1:1504 BLACKCOMBE ST UNIT 204
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-8019
Practice Address - Country:US
Practice Address - Phone:404-849-9918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Multi-Specialty
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic MedicineGroup - Multi-Specialty
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1245755636Medicaid
NV1821367087Medicaid