MEDICARE: BLAKE NELSON BERRY

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	225C00000X	Rehabilitation Counselor		NV

General Provider Information

NPI Number	:	1548537772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE NELSON BERRY

Provider Business Mailing Address
First Line	:	1481 W WARM SPRINGS RD
Second Line	:	129
City	:	HENDERSON
State	:	NV
Zip	:	89014-7633
Country	:	US
Telephone Number	:	702-806-8618
Fax Number	:	702-944-7846

Provider Business Practice Location Address
First Line	:	1481 W WARM SPRINGS RD
Second Line	:	129
City	:	HENDERSON
State	:	NV
Zip	:	89014-7633
Country	:	US
Telephone Number	:	702-806-8618
Fax Number	:	702-944-7846

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

Provider Enumeration Date	:	11/16/2011
Last Update Date	:	11/16/2011

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Directions to “ BLAKE NELSON BERRY ” Practice Location

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