Provider Demographics
NPI:1699158600
Name:FUNDAMENTAL BEHAVIORAL SERVICES LLC
Entity type:Organization
Organization Name:FUNDAMENTAL BEHAVIORAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-338-8373
Mailing Address - Street 1:2921 N. TENAYA WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0454
Mailing Address - Country:US
Mailing Address - Phone:702-683-2591
Mailing Address - Fax:702-645-2874
Practice Address - Street 1:3035 S. MARYLAND PARKWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109
Practice Address - Country:US
Practice Address - Phone:702-978-8100
Practice Address - Fax:702-857-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health