MEDICARE: MATTHEW SCOTT DUSTIN LCSW

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	1041C0700X	Clinical Social Worker	6118-C	NV

General Provider Information

NPI Number	:	1861720047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW SCOTT DUSTIN LCSW

Provider Business Mailing Address
First Line	:	3421 BRAYTON MIST DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6527
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6070 S EASTERN AVE
Second Line	:	#200
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3171
Country	:	US
Telephone Number	:	702-292-3774
Fax Number	:

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

Provider Enumeration Date	:	11/25/2009
Last Update Date	:	04/04/2012

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