MEDICARE: BATTLE-BORN PSYCHOLOGICAL SERVICES, 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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1912377482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BATTLE-BORN PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	5836 BELUGA BAY ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6843
Country	:	US
Telephone Number	:	702-941-0583
Fax Number	:	702-518-0966

Provider Business Practice Location Address
First Line	:	5836 BELUGA BAY ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6843
Country	:	US
Telephone Number	:	702-941-0583
Fax Number	:	702-518-0966

Authorized Official
Title or Position	:	CEO & PRIMARY CONSULTANT
Name	:	DR. EARNEST HOWARD-RUDOLPH BLACKSHEAR
Credential	:	PHD
Telephone Number	:	702-941-0583

Provider Enumeration Date	:	09/28/2015
Last Update Date	:	04/13/2022

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