MEDICARE: QUANI BURGESS

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	103K00000X	Behavior Analyst
2	103K00000X	Behavior Analyst		NV

General Provider Information

NPI Number	:	1598177677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUANI BURGESS

Provider Business Mailing Address
First Line	:	2362 N GREEN VALLEY PKWY
Second Line	:	#97
City	:	HENDERSON
State	:	NV
Zip	:	89014-3661
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2362 N GREEN VALLEY PKWY
Second Line	:	#97
City	:	HENDERSON
State	:	NV
Zip	:	89014-3661
Country	:	US
Telephone Number	:	702-350-6124
Fax Number	:

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

Provider Enumeration Date	:	05/23/2014
Last Update Date	:	05/23/2014

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Directions to “ QUANI BURGESS ” Practice Location

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