MEDICARE: THERAPY SOURCE OF NEVADA, LLC

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	225XP0200X	Pediatric Occupational Therapist	0324	NV

General Provider Information

NPI Number	:	1851631196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPY SOURCE OF NEVADA, LLC

Provider Business Mailing Address
First Line	:	2654 W HORIZON RIDGE PKWY
Second Line	:	SUITE B5 PMB 322
City	:	HENDERSON
State	:	NV
Zip	:	89052-2803
Country	:	US
Telephone Number	:	702-683-7617
Fax Number	:	702-837-3422

Provider Business Practice Location Address
First Line	:	1614 WATERFORD FALLS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-5873
Country	:	US
Telephone Number	:	702-683-7617
Fax Number	:	702-837-3422

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	SUSAN MINNICK
Credential	:	OTR/L
Telephone Number	:	702-683-7617

Provider Enumeration Date	:	02/24/2013
Last Update Date	:	02/24/2013

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