MEDICARE: BRENDA SMITH BRAAM

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	NV20121718942	NV

General Provider Information

NPI Number	:	1740527795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA SMITH BRAAM

Provider Business Mailing Address
First Line	:	PO BOX 775
Second Line	:
City	:	RUTHER GLEN
State	:	VA
Zip	:	22546-0775
Country	:	US
Telephone Number	:	702-325-9226
Fax Number	:

Provider Business Practice Location Address
First Line	:	4616 W SAHARA AVE # 139
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-3654
Country	:	US
Telephone Number	:	702-325-9226
Fax Number	:

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

Provider Enumeration Date	:	01/10/2013
Last Update Date	:	01/10/2013

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