MEDICARE: HEATHER LYNN BROCKWAY LSW

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	225400000X	Rehabilitation Practitioner
2	104100000X	Social Worker	5839-S	NV

General Provider Information

NPI Number	:	1578867875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER LYNN BROCKWAY LSW

Provider Business Mailing Address
First Line	:	10100 ELIDA RD
Second Line	:
City	:	DELPHOS
State	:	OH
Zip	:	45833-9056
Country	:	US
Telephone Number	:	419-695-8010
Fax Number	:	419-694-0004

Provider Business Practice Location Address
First Line	:	4285 N RANCHO DR
Second Line	:	STE 130
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3446
Country	:	US
Telephone Number	:	702-385-5331
Fax Number	:	702-385-5678

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

Provider Enumeration Date	:	12/29/2010
Last Update Date	:	09/19/2019

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