MEDICARE: STACEY J SHADOFF MFT

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	39346	NV
2	103K00000X	Behavior Analyst	39346	CA

General Provider Information

NPI Number	:	1679880249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY J SHADOFF MFT

Provider Business Mailing Address
First Line	:	2350 S JONES BLVD # 227
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3103
Country	:	US
Telephone Number	:	702-214-2140
Fax Number	:	702-215-5821

Provider Business Practice Location Address
First Line	:	2350 S JONES BLVD # 227
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3103
Country	:	US
Telephone Number	:	702-214-2140
Fax Number	:	702-215-5821

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

Provider Enumeration Date	:	09/02/2010
Last Update Date	:	09/02/2010

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