MEDICARE: DAWIT GOLLA

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	:	1609110550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWIT GOLLA

Provider Business Mailing Address
First Line	:	5415 W HARMON AVE UNIT 2076
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-7022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5415 W HARMON AVE UNIT 2076
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-7022
Country	:	US
Telephone Number	:	702-290-9289
Fax Number	:

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

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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Directions to “ DAWIT GOLLA ” Practice Location

Language	Start Address	Practice Location

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