MEDICARE: MR. CLINTON ANTHONY ROSSUM JR.

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1013330265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLINTON ANTHONY ROSSUM JR.

Provider Business Mailing Address
First Line	:	5841 FERAL GARDEN ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-6894
Country	:	US
Telephone Number	:	602-330-8607
Fax Number	:

Provider Business Practice Location Address
First Line	:	5841 FERAL GARDEN ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-6894
Country	:	US
Telephone Number	:	602-330-8607
Fax Number	:

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

Provider Enumeration Date	:	01/23/2014
Last Update Date	:	01/23/2014

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