Provider Demographics
NPI:1386923506
Name:R.E.S.T.O.R.E. BEHAVIORAL HEALTH REHABILITATIVE TREATMENT SERVICES,LLC
Entity type:Organization
Organization Name:R.E.S.T.O.R.E. BEHAVIORAL HEALTH REHABILITATIVE TREATMENT SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CADC-I
Authorized Official - Phone:404-449-3463
Mailing Address - Street 1:3925 NORTH MARTIN LUTHER KING BLVD.
Mailing Address - Street 2:SUITE 215
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-7676
Mailing Address - Country:US
Mailing Address - Phone:404-449-3463
Mailing Address - Fax:702-990-2063
Practice Address - Street 1:3925 NORTH MARTIN LUTHER KING BLVD.
Practice Address - Street 2:SUITE 215
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-7676
Practice Address - Country:US
Practice Address - Phone:404-449-3463
Practice Address - Fax:702-990-2063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20111522035103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1386923506Medicaid