MEDICARE: MISS EBONY THEODESIA CARTER

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

General Provider Information

NPI Number	:	1326325002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS EBONY THEODESIA CARTER

Provider Business Mailing Address
First Line	:	5370 E CRAIG RD APT 2342
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-2182
Country	:	US
Telephone Number	:	702-764-1255
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 VEGAS DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2422
Country	:	US
Telephone Number	:	702-764-1255
Fax Number	:

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

Provider Enumeration Date	:	11/09/2011
Last Update Date	:	12/10/2013

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