MEDICARE: MS. VICTORIA KAY DACOSTA RDH, CMT

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

General Provider Information

NPI Number	:	1215490289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICTORIA KAY DACOSTA RDH, CMT

Provider Business Mailing Address
First Line	:	9004 DOLENTE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6122
Country	:	US
Telephone Number	:	702-980-4199
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 W CHEYENNE AVE STE 100
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8223
Country	:	US
Telephone Number	:	702-787-2116
Fax Number	:

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

Provider Enumeration Date	:	04/08/2019
Last Update Date	:	04/08/2019

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