MEDICARE: JOHNA QUIN JA VEA MCDANIEL CPC INTERN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1104598127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNA QUIN JA VEA MCDANIEL CPC INTERN

Provider Business Mailing Address
First Line	:	3376 S EASTERN AVE STE 160
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-3388
Country	:	US
Telephone Number	:	702-490-9009
Fax Number	:	866-737-6147

Provider Business Practice Location Address
First Line	:	3376 S EASTERN AVE STE 160
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-3388
Country	:	US
Telephone Number	:	702-490-9009
Fax Number	:	866-737-6147

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

Provider Enumeration Date	:	09/28/2021
Last Update Date	:	09/28/2021

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