MEDICARE: MARIO WOLTHERS JR.

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1403177618	OTHER	NV	DRIVERS LICENSE

General Provider Information

NPI Number	:	1396268793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO WOLTHERS JR.

Provider Business Mailing Address
First Line	:	2575 MONTESSOURI ST STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3060
Country	:	US
Telephone Number	:	702-587-8106
Fax Number	:

Provider Business Practice Location Address
First Line	:	2575 MONTESSOURI ST STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3060
Country	:	US
Telephone Number	:	702-587-8106
Fax Number	:

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

Provider Enumeration Date	:	07/18/2017
Last Update Date	:	07/21/2022

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Directions to “ MARIO WOLTHERS JR. ” Practice Location

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