MEDICARE: PROACTIVE AUTISM SOLUTIONS, INC.

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	LBA0042	NV

General Provider Information

NPI Number	:	1619380581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE AUTISM SOLUTIONS, INC.

Provider Business Mailing Address
First Line	:	6767 W CHARLESTON BLVD
Second Line	:	STE. 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-9073
Country	:	US
Telephone Number	:	760-291-7160
Fax Number	:

Provider Business Practice Location Address
First Line	:	6767 W CHARLESTON BLVD
Second Line	:	STE. 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-9073
Country	:	US
Telephone Number	:	760-291-7160
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT AND DIRECTOR OF COMPANY
Name	:	ANGELA PATRICELLI
Credential	:	BCBA, LBA
Telephone Number	:	760-291-7160

Provider Enumeration Date	:	06/08/2014
Last Update Date	:	06/08/2014

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