MEDICARE: MR. JONATHAN R WOTELL CPC I

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	101YP2500X	Professional Counselor	CI1599	NV
2	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1942509930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN R WOTELL CPC I

Provider Business Mailing Address
First Line	:	5631 S. PECOS ROAD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120
Country	:	US
Telephone Number	:	702-685-0877
Fax Number	:	702-749-5922

Provider Business Practice Location Address
First Line	:	5631 S. PECOS ROAD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120
Country	:	US
Telephone Number	:	702-685-0877
Fax Number	:	702-749-5922

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

Provider Enumeration Date	:	03/16/2011
Last Update Date	:	05/12/2021

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