MEDICARE: KATHLEEN RISDON LCSW, LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	135-L	NV
2	1041C0700X	Clinical Social Worker	00132-C	NV

General Provider Information

NPI Number	:	1174969380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN RISDON LCSW, LADC

Provider Business Mailing Address
First Line	:	1640 ALTA DR
Second Line	:	#4
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4163
Country	:	US
Telephone Number	:	702-474-6450
Fax Number	:	702-474-6463

Provider Business Practice Location Address
First Line	:	1640 ALTA DR
Second Line	:	#4
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4163
Country	:	US
Telephone Number	:	702-474-6450
Fax Number	:	702-474-6463

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

Provider Enumeration Date	:	05/14/2013
Last Update Date	:	05/14/2013

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