MEDICARE: ANN BLYTH BULLIS 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	4209-C	NV

General Provider Information

NPI Number	:	1336365139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANN BLYTH BULLIS LCSW

Provider Business Mailing Address
First Line	:	998 CLEAR DIAMOND AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-3687
Country	:	US
Telephone Number	:	702-456-8312
Fax Number	:	702-651-3503

Provider Business Practice Location Address
First Line	:	2801 S VALLEY VIEW BLVD
Second Line	:	#14
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-0116
Country	:	US
Telephone Number	:	702-243-4357
Fax Number	:	702-228-0735

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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