MEDICARE: MYRA THOMPSON, PSYD, LLC

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	103T00000X	Psychologist	PY0739	NV
2	251S00000X	Community/Behavioral Health Agency	PY0739	NV

General Provider Information

NPI Number	:	1518317759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYRA THOMPSON, PSYD, LLC

Provider Business Mailing Address
First Line	:	PO BOX 400755
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89140-0755
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6069 S FORT APACHE RD
Second Line	:	#100
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-5647
Country	:	US
Telephone Number	:	702-444-1373
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MYRA THOMPSON
Credential	:	PSY.D.
Telephone Number	:	702-444-1373

Provider Enumeration Date	:	06/19/2016
Last Update Date	:	10/15/2016

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