MEDICARE: BERTHA JEANIE BANKS

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
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1033401021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERTHA JEANIE BANKS

Provider Business Mailing Address
First Line	:	4435 MATINEE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4435 MATINEE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-0417
Country	:	US
Telephone Number	:	702-696-8091
Fax Number	:

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

Provider Enumeration Date	:	05/09/2011
Last Update Date	:	05/09/2011

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