MEDICARE: ELLANISHA LATASHA BRYANT

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164772802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLANISHA LATASHA BRYANT

Provider Business Mailing Address
First Line	:	3145 E FLAMINGO RD
Second Line	:	2008
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4352
Country	:	US
Telephone Number	:	702-782-4122
Fax Number	:

Provider Business Practice Location Address
First Line	:	3145 E FLAMINGO RD
Second Line	:	APT 2008
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4352
Country	:	US
Telephone Number	:	702-782-4122
Fax Number	:

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

Provider Enumeration Date	:	09/10/2012
Last Update Date	:	09/10/2012

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Directions to “ ELLANISHA LATASHA BRYANT ” Practice Location

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