MEDICARE: MAIMOUNA ROSE CANTRALL CPC-I

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
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1174996201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAIMOUNA ROSE CANTRALL CPC-I

Provider Business Mailing Address
First Line	:	767 CANYON CREST DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-0533
Country	:	US
Telephone Number	:	702-589-0701
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 E DESERT INN RD STE 104
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-2505
Country	:	US
Telephone Number	:	702-208-2194
Fax Number	:

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

Provider Enumeration Date	:	11/11/2015
Last Update Date	:	04/24/2024

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