MEDICARE: PATRICIA SELF OT

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	174400000X	Specialist	Z12200	LA

General Provider Information

NPI Number	:	1932339272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA SELF OT

Provider Business Mailing Address
First Line	:	4905 ROYAL LAKE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-3684
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4905 ROYAL LAKE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-3684
Country	:	US
Telephone Number	:	435-525-1216
Fax Number	:

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

Provider Enumeration Date	:	07/21/2009
Last Update Date	:	11/22/2014

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Directions to “ PATRICIA SELF OT” Practice Location

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