Basic Information
| Provider Information | |||||||||
| NPI: | 1346536927 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CSSI BEHAVIORAL HEALTH SERVICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CSSI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3620 N RANCHO DR STE 111 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891303154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026394400 | ||||||||
| FaxNumber: | 7026394403 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 N RANCHO DR STE 111 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891303154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026394400 | ||||||||
| FaxNumber: | 7026394403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TELLIS | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7026394400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 251B00000X | Y | Agencies | Case Management |
No ID Information.