MEDICARE: GWENDOLYN HARRIS-HABERSHAM

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	106S00000X	Behavior Technician	RBT5701	NV

General Provider Information

NPI Number	:	1780561654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN HARRIS-HABERSHAM

Provider Business Mailing Address
First Line	:	1707 VILLAGE CENTER CIR STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-0577
Country	:	US
Telephone Number	:	702-766-9840
Fax Number	:

Provider Business Practice Location Address
First Line	:	1707 VILLAGE CENTER CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6438
Country	:	US
Telephone Number	:	702-766-9840
Fax Number	:

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

Provider Enumeration Date	:	08/20/2025
Last Update Date	:	08/20/2025

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Directions to “ GWENDOLYN HARRIS-HABERSHAM ” Practice Location

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