MEDICARE: BETHSABE SURYA CPC INTERN

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	CI764	NV

General Provider Information

NPI Number	:	1821699000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHSABE SURYA CPC INTERN

Provider Business Mailing Address
First Line	:	3808 VINCELLI AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-4811
Country	:	US
Telephone Number	:	702-581-7130
Fax Number	:

Provider Business Practice Location Address
First Line	:	3808 VINCELLI AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-4811
Country	:	US
Telephone Number	:	702-581-7130
Fax Number	:

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

Provider Enumeration Date	:	11/04/2020
Last Update Date	:	11/04/2020

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