Healthcare Provider Details

I. General information

NPI: 1376298364
Provider Name (Legal Business Name): BRUCE EDWARD BROWN RBT, LBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S RANCHO DR STE A
LAS VEGAS NV
89106-4849
US

IV. Provider business mailing address

630 S RANCHO DR STE D
LAS VEGAS NV
89106-4849
US

V. Phone/Fax

Practice location:
  • Phone: 702-998-9505
  • Fax: 702-527-4579
Mailing address:
  • Phone: 702-844-4579
  • Fax: 702-527-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-191694
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: