MEDICARE: SUPPORTIVE COUNSELING, LLC

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

General Provider Information

NPI Number	:	1538747043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE COUNSELING, LLC

Provider Business Mailing Address
First Line	:	8708 TOMNITZ AVE UNIT 101
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-6715
Country	:	US
Telephone Number	:	702-600-9753
Fax Number	:

Provider Business Practice Location Address
First Line	:	8708 TOMNITZ AVE UNIT 101
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-6715
Country	:	US
Telephone Number	:	702-600-9753
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	BRIANNA SHACOLE MARSHALL
Credential	:	LCSW
Telephone Number	:	702-600-9753

Provider Enumeration Date	:	03/29/2021
Last Update Date	:	03/30/2021

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