MEDICARE: JELLY MAE MCCAULEY RBT

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	RBT 15-08788	NV

General Provider Information

NPI Number	:	1184170680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JELLY MAE MCCAULEY RBT

Provider Business Mailing Address
First Line	:	429 DON PEDRO CIR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2835
Country	:	US
Telephone Number	:	702-768-3827
Fax Number	:

Provider Business Practice Location Address
First Line	:	429 DON PEDRO CIR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2835
Country	:	US
Telephone Number	:	702-768-3827
Fax Number	:

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

Provider Enumeration Date	:	08/25/2016
Last Update Date	:	08/25/2016

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