MEDICARE: LATRICE CHERI MATTOX-MITCHELL

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	101Y00000X	Counselor
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1104362870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATRICE CHERI MATTOX-MITCHELL

Provider Business Mailing Address
First Line	:	4525 S SANDHILL RD STE 106
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5955
Country	:	US
Telephone Number	:	702-848-1696
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 S SANDHILL RD STE 106
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5955
Country	:	US
Telephone Number	:	702-848-1696
Fax Number	:

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

Provider Enumeration Date	:	01/18/2017
Last Update Date	:	01/18/2017

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