MEDICARE: GAVIN LANELL JOHNSON

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336481696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAVIN LANELL JOHNSON

Provider Business Mailing Address
First Line	:	7720 COWBOY TRAIL
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131
Country	:	US
Telephone Number	:	702-510-3790
Fax Number	:

Provider Business Practice Location Address
First Line	:	7720 COWBOY TRL
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-2131
Country	:	US
Telephone Number	:	702-510-3790
Fax Number	:

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

Provider Enumeration Date	:	03/25/2013
Last Update Date	:	03/25/2013

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Directions to “ GAVIN LANELL JOHNSON ” Practice Location

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