MEDICARE: JUSTICE DOUGLAS

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1134999378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTICE DOUGLAS

Provider Business Mailing Address
First Line	:	5732 SALT ROCK ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-1326
Country	:	US
Telephone Number	:	702-884-6266
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 W CHEYENNE AVE STE 60
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7850
Country	:	US
Telephone Number	:	702-633-7923
Fax Number	:

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

Provider Enumeration Date	:	01/08/2024
Last Update Date	:	01/08/2024

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Directions to “ JUSTICE DOUGLAS ” Practice Location

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