MEDICARE: GENESIS LIGHTBOURNE

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
2	1041C0700X	Clinical Social Worker	12959-C	NV
3	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1649543471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENESIS LIGHTBOURNE

Provider Business Mailing Address
First Line	:	1640 E FLAMINGO RD
Second Line	:	#100
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5249
Country	:	US
Telephone Number	:	702-503-9544
Fax Number	:

Provider Business Practice Location Address
First Line	:	3925 MARTIN LUTHER KING B
Second Line	:	SUITE 212
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032
Country	:	US
Telephone Number	:	702-503-9544
Fax Number	:

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

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	03/11/2026

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Directions to “ GENESIS LIGHTBOURNE ” Practice Location

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