MEDICARE: DR. HAVI BRYSK MANDELL PH.D., MSW, LCSW

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	1041C0700X	Clinical Social Worker	5276-C	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1881724250	OTHER	NV	JFSA

General Provider Information

NPI Number	:	1255529897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAVI BRYSK MANDELL PH.D., MSW, LCSW

Provider Business Mailing Address
First Line	:	4794 S EASTERN AVE
Second Line	:	SUITE C
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6145
Country	:	US
Telephone Number	:	702-732-0304
Fax Number	:	702-794-2033

Provider Business Practice Location Address
First Line	:	4794 S EASTERN AVE
Second Line	:	SUITE C
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6145
Country	:	US
Telephone Number	:	702-732-0304
Fax Number	:	702-794-2033

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

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	02/05/2008

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