MEDICARE: MR. LEWIS M ETCOFF PH.D.

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	103TC0700X	Clinical Psychologist	PY129	NV

General Provider Information

NPI Number	:	1225154305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEWIS M ETCOFF PH.D.

Provider Business Mailing Address
First Line	:	8475 S EASTERN AVE
Second Line	:	SUITE 205
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-2862
Country	:	US
Telephone Number	:	702-876-1977
Fax Number	:	702-876-0238

Provider Business Practice Location Address
First Line	:	8475 S EASTERN AVE
Second Line	:	SUITE 205
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-2862
Country	:	US
Telephone Number	:	702-876-1977
Fax Number	:	702-876-0238

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/08/2007

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