Basic Information
| Provider Information | |||||||||
| NPI: | 1114400934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | DOMINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 HARRIS SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891249215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028725382 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 HARRIS SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891249215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028725382 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2018 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 02295-I | NV | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.