MEDICARE: EDRECKA WOLRIDGE

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	:	1710489513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDRECKA WOLRIDGE

Provider Business Mailing Address
First Line	:	4103 W DELHI AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-3419
Country	:	US
Telephone Number	:	702-578-1978
Fax Number	:

Provider Business Practice Location Address
First Line	:	4103 W DELHI AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-3419
Country	:	US
Telephone Number	:	702-578-1978
Fax Number	:

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

Provider Enumeration Date	:	03/07/2018
Last Update Date	:	03/07/2018

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Directions to “ EDRECKA WOLRIDGE ” Practice Location

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