Basic Information
| Provider Information | |||||||||
| NPI: | 1891869897 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDERSON SPEECH HEARING AND LANGUAGE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 331 N BUFFALO DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891450300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027338255 | ||||||||
| FaxNumber: | 7027378255 | ||||||||
| Practice Location | |||||||||
| Address1: | 331 N BUFFALO DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891450300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027338255 | ||||||||
| FaxNumber: | 7027378255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 03/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | MANDEL | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7027338255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 100507443 | 05 | NV | MEDICAID |