MEDICARE: MRS. TOMMIE K FORAGE 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	5773C	NV

General Provider Information

NPI Number	:	1932402765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TOMMIE K FORAGE LCSW

Provider Business Mailing Address
First Line	:	5145 S DURANGO DR
Second Line	:	SUITE 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-0191
Country	:	US
Telephone Number	:	702-726-0709
Fax Number	:	702-248-2008

Provider Business Practice Location Address
First Line	:	5145 S DURANGO DR
Second Line	:	SUITE 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-0191
Country	:	US
Telephone Number	:	702-726-0709
Fax Number	:	702-248-2008

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

Provider Enumeration Date	:	12/16/2010
Last Update Date	:	12/16/2010

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