MEDICARE: LAURIE ANN RIELLY-JOHNSON

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

General Provider Information

NPI Number	:	1881169126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE ANN RIELLY-JOHNSON

Provider Business Mailing Address
First Line	:	6130 W TROPICANA AVE STE 145
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-4604
Country	:	US
Telephone Number	:	702-900-7698
Fax Number	:	702-825-0791

Provider Business Practice Location Address
First Line	:	6130 W TROPICANA AVE STE 145
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-4604
Country	:	US
Telephone Number	:	702-900-7698
Fax Number	:	702-825-0791

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

Provider Enumeration Date	:	10/12/2018
Last Update Date	:	06/11/2019

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