MEDICARE: OSOM BEHAVIOR MANAGEMENT

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	251S00000X	Community/Behavioral Health Agency	NV20101771798	NV

General Provider Information

NPI Number	:	1386922136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OSOM BEHAVIOR MANAGEMENT

Provider Business Mailing Address
First Line	:	2616 SLIDE CANYON AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081
Country	:	US
Telephone Number	:	702-981-0391
Fax Number	:

Provider Business Practice Location Address
First Line	:	2616 SLIDE CANYON AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081
Country	:	US
Telephone Number	:	702-981-0391
Fax Number	:

Authorized Official
Title or Position	:	CEO/PSYCHOSOCIAL REHABILITATIVE SPE
Name	:	MR. WALLACE E. HARRIS II
Credential	:	MS ED.
Telephone Number	:	702-981-0391

Provider Enumeration Date	:	07/28/2011
Last Update Date	:	07/28/2011

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