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NPI Code Detail

MEDICARE: MICHELLANE HAZEL MOUTON

MEDICARE: MICHELLANE HAZEL MOUTON
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
1103T00000XPsychologist

General Provider Information

NPI Number : 1912424045
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHELLANE HAZEL MOUTON
Provider Business Mailing Address
First Line : 9206 W RUSSELL RD # 2-212
Second Line :
City : LAS VEGAS
State : NV
Zip : 89148-1217
Country : US
Telephone Number : 702-290-6504
Fax Number :
Provider Business Practice Location Address
First Line : 7000 SPRING MOUNTAIN RD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89117-3816
Country : US
Telephone Number : 702-873-2400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/29/2017
Last Update Date : 08/29/2017

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Directions to “ MICHELLANE HAZEL MOUTON ” Practice Location

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