MEDICARE: DIONNE ETHEL WEBSTER MA PSYCHOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103K00000X	Behavior Analyst
3	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1306400155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIONNE ETHEL WEBSTER MA PSYCHOLOGY

Provider Business Mailing Address
First Line	:	3826 CARIBBEAN BLUE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-3618
Country	:	US
Telephone Number	:	702-482-5159
Fax Number	:

Provider Business Practice Location Address
First Line	:	3560 W CHEYENNE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8260
Country	:	US
Telephone Number	:	702-331-1917
Fax Number	:

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

Provider Enumeration Date	:	04/26/2019
Last Update Date	:	04/26/2019

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