MEDICARE: MATTHEW LAWRENCE TOLLESON B.S.

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	101YM0800X	Mental Health Counselor
2	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1811206014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW LAWRENCE TOLLESON B.S.

Provider Business Mailing Address
First Line	:	2831 SAINT ROSE PKWY
Second Line	:	SUITE 236
City	:	HENDERSON
State	:	NV
Zip	:	89052-4840
Country	:	US
Telephone Number	:	702-589-4869
Fax Number	:	702-589-4866

Provider Business Practice Location Address
First Line	:	2831 SAINT ROSE PKWY
Second Line	:	SUITE 236
City	:	HENDERSON
State	:	NV
Zip	:	89052-4840
Country	:	US
Telephone Number	:	702-589-4869
Fax Number	:	702-589-4866

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

Provider Enumeration Date	:	10/05/2010
Last Update Date	:	11/22/2011

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