MEDICARE: PORSCHA MENYWEATHER

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	103TC2200X	Clinical Child & Adolescent Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275871238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PORSCHA MENYWEATHER

Provider Business Mailing Address
First Line	:	4316 E TROPICANA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-6704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4316 E TROPICANA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-6704
Country	:	US
Telephone Number	:	702-420-0028
Fax Number	:

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

Provider Enumeration Date	:	01/26/2013
Last Update Date	:	01/26/2013

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Directions to “ PORSCHA MENYWEATHER ” Practice Location

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