MEDICARE: SHANA QUINN BACHUS BASW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	225400000X	NV

General Provider Information

NPI Number	:	1003115643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA QUINN BACHUS BASW

Provider Business Mailing Address
First Line	:	PO BOX 27794
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89126-1794
Country	:	US
Telephone Number	:	702-202-5680
Fax Number	:

Provider Business Practice Location Address
First Line	:	4801 SPENCER ST APT 158
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6263
Country	:	US
Telephone Number	:	702-202-5680
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	03/22/2011

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