MEDICARE: MIKE WALLER

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	:	1487941811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE WALLER

Provider Business Mailing Address
First Line	:	4430 VERDUGO ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-4777
Country	:	US
Telephone Number	:	702-321-8493
Fax Number	:

Provider Business Practice Location Address
First Line	:	4430 VERDUGO ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-4777
Country	:	US
Telephone Number	:	702-321-8493
Fax Number	:

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

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	07/06/2011

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