MEDICARE: ROSEANNE ELLEN PORTER

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	1602971403	NV

General Provider Information

NPI Number	:	1053759951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSEANNE ELLEN PORTER

Provider Business Mailing Address
First Line	:	1109 SOUTH EMERYWOOD COURT
Second Line	:	UNIT D
City	:	LAS VEGAS
State	:	NV
Zip	:	89117
Country	:	US
Telephone Number	:	702-884-9017
Fax Number	:

Provider Business Practice Location Address
First Line	:	1109 EMERYWOOD CT
Second Line	:	UNITD
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-9041
Country	:	US
Telephone Number	:	702-884-9017
Fax Number	:

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

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	06/13/2013

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