MEDICARE: JULIA MARIE MARANVILLE PSYCHOLOGY STUDENT

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1407532369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIA MARIE MARANVILLE PSYCHOLOGY STUDENT

Provider Business Mailing Address
First Line	:	6460 MEDICAL CENTER ST STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2406
Country	:	US
Telephone Number	:	702-888-1340
Fax Number	:	702-888-1342

Provider Business Practice Location Address
First Line	:	6460 MEDICAL CENTER ST STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2406
Country	:	US
Telephone Number	:	702-888-1340
Fax Number	:	702-888-1342

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

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	06/26/2023

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